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HomeMy WebLinkAbout2018 THIRD PARTY ADMINISTRATOR (TPA) AND STOP LOSS AGREEMENTS WITH BLUE CROSS BLUE SHIELD Rate Summary Exhibit 1 BlueCross BlueShield Augusta Richmond County ooh / of Georgia Medical Administrative Services Only(ASO) 01101118.12131118 Contract Type.Paid I Composite I Monthly I Annual Effective Date. 1 1 20181 Rate Enrollment Assumption 2341 ,,_ �.,•.:,' ,.,,i,_:,_.. : >... ,_ , - Administration Fee* $42.47 $99,422 $1,193,067 ACA Reinsurance Fee See Below See Below See Below Specific Stoploss $225,000 $43.60 $102,06; $1,224,811 Aggregate Stoploss None $0.00 $1 $0 Commission N 1 t, ,.x, ,. :-.V4314'';a',",;:,;,::.,. !"^-'� 'V .,,. ,. �= ? ., .,.2 I . . . ' .. .fin This quote includes an Aggregating Specific Deductible of$250,000 w. :. 1 !:',7 , ,:2:?.fi ,, it , ' 'F0 ',TM .i,'` - z:'-": i , Expected Claim Liability(ECL) $702.68 $1,644,981 $19,739,769 Maximum Claim Liability(MCL) N/A NA NA ,! Fixed+ECL $788.75 $1,846,471 ��$22,157,647 Fixed+MCL #VALUE! NA NA Estimated Claims Cost NA NA Proposal date: 9/27/2017 Additional Fees(ACA):Client Pays ACA Fees Directly to Gvt ACA Reinsurance PMPM PCPM I : ,i rr .1.1r 2019 $0.00 *Stop loss quote is illustrative pending updated monthly claims and high claim detail through 10/01/2017 *Rx is carved out. Fees include$1.65 PCPM for Rx carve-out services. *Additional charges may apply to administer Rx OOP Commingling due to Rx carve-out Contact your BCBSGa Account Executive or Account Manager to discuss options for commingling the pharmacy and medical OOP maximums. *Composite rates are developed from whole case census. *Wellness and Implementation funds of$100,000 available per year.Assumes average enrollment of 2,341. Not to be carried over from one year to the next. *Groups with less than 250 enrolled employees will not be eligible for carving out stop-loss. *The SSL accumulation period will be Incurred:01/01/2013-12/31/2018 and Paid:01/01/2018-12/31/2018. SSL rates include no commissions. *The ASL accumulation period will be Incurred:NA-NA and Paid:NA-NA.ASL rates include no commissions. *All rates will be billed on a Composite basis. *Dental rates(if applicable)not included above.Vision rates(it applicable)not included above. *HSA and HRA administration fees are not included in the rates but can be added to any consumer driven health plan. *ASO base fee cap of 0.0%,for renewal in 2019*No renewal fee caps *Traditional Medical Plan-CHS Programs Included:24/7 Nurse line,Anthem Cancer Care Quality Program,Anthem Health Rewards, ConditionCare Core 5,Future Moms with ID,Integrated Imaging,Healthy Lifestyles Online,Radiation Therapy,Sleep,Specialty Pharmacy with Clinical Site of Care Review,LiveHealth Online,ComplexCare. ., 40,1111M111414 4.44W.VAN AfaiNk 4 • es (14 I accept the rates,plan numbers and renewal effective date -•above and un.: �f ret-_-n �` 1; benefits are subject to change o final ACA guid-- is es d and rfevie P A ',1i+, I! s e rR r'4"1k . ,y� •t Employer Signature � i" .r } !I tirif v Print Employer Name 17 F rot—ft �i.fir. /i'/1i 146-14;::*l�r / - I_ 1 L ♦• {. w(7 // . • 31/1 7 Sales Representative. '� ill ii Augusta Richmond County ( BlueCross BlueShielc Loss Assumttons of Georgia Underwriting General Terms and Conditions Effective date is: 1/1/2018 The proposal assumes the same enrollment for Medical and Drug and is based on the following enrollment assumptions: Agents commission included on stop loss: Single EE/So EE/Ch Family Total Aggregate stop loss 0.0% 1,035 432 258 616 2,341 Specific stop loss 0.0% •This contract will be issued in Georgia. •Quote assumes that 2,341 employees will be enrolling for medical coverage,with an average member to employee ratio of 2.19. •The proposed stop loss rates are effective from 01/01/18 through 12/31/18 •Blue Cross Blue Shield of Georgia reserves the right to revise this proposal or modify these rates under any of the following circumstances: •Due to any taxes,fees and assessments prescribed by any statutory,regulatory or other legal authority,that in Blue Cross Blue Shield of Georgia's discretion, invalidates this quote. •Should the employer implement benefit changes that result in substantial changes in the service or networks,as determined by Blue Cross Blue Shield of Georgia •Change in nature of Employer's business •Should the total enrollment or enrollment distribution by membership type,product or location change by 10%or more from that assumed when preparing the pricing for this package. •If legislative and/or regulatory changes or mandates materially impact the stop loss policy or the Employer's plan documents.Plan documents shall include the documents that set forth the terms of the plan. •Changes in proposal terms,conditions,services or product from this quotation. •We will rely on the information provided to determine whether a proposal will be issued.The information provided shall become a part of the application for stop loss coverage.You are obligated to provide accurate information.If material errors or omissions are found after the quote is issued,we reserve the right to revise the quote in any manner or rescind the quote even if you were unaware of the material error or omission.Additionally,we reserve the right to rescind the proposal in its entirety based on our review of all the information submitted during the proposal process. Caveats •Carve-Out pharmacy claims will be included in the specific stop-loss. •This proposal is based on an aggregating deductible of$250,000 in conjunction with the specific deductible being proposed. •This proposal expires 90 days from the date of its release or on the effective date shown above,whichever is sooner. •The annual specific attachment point is per member per contract period. •The specific maximum liability for any individual will be unlimited. •The renewal notification will be provided no sooner than 90 days prior to the renewal effective date. •Proposed rates are payable by the invoice due date. •Proposed specific stop loss rates assume that the employer will continue its current level of contributions, •Proposed specific stop loss rates assume that 100%of eligible employees and dependents will participate if noncontributory and 75%will participate if the plan is contributory. •Specific Stop Loss Attachment points include paid Medical and Rx claims, •Stop Loss protection must be purchased in conjunction with BCBS GA's Administrative Services proposal •No change in benefits provided by the group's employee benefit program shall be covered by the stop loss agreement nor shall any amounts paid as benefits resulting from such a change be counted towards the satisfaction of the attachment point.This limitation may be waived if a written acceptance of such a change is issued by the carrier. •Only those coverages quoted and which are eligible under the group's employee benefit program are eligible under this stop loss program. •Please refer to our specific Stop Loss Agreement for complete details. •Specific Stop loss claims above the selected specific stop loss deductible limit will NOT count towards satisfaction of the aggregate attachment point. •BCBSGA is entitled to reimbursement of benefits paid if the member recovers damages from a legally liable third party. Group Specific Caveats *Groups with less than 250 enrolled employees will not be eligible for carving out stop-loss. •This proposal assumes that Blue Cross Blue Shield of Georgia will be the only carrier offered • SSL rates include no commissions.ASL not elected. •This quotation assumes the purchase of Blue Cross Blue Shield of Georgia administrated Stop Loss. If Augusta Richmond County chooses to utilize an outside Stop Loss vendor,a coordination charge of$2.00 will apply. •The rates provided assume there is no member reimbursement which reduces the out-of-pocket cost of the benefit plan. Rates may be adjusted if out-of-pocket costs are subsidized by the employer. Modifications •Proposals are subject to review of audited financial statements and Dun&Bradstreet reports prior to final sale. •Stop Loss rates are ILLUSTRATIVE due to the gap in the experience period and effective date of coverage.In order to provide a firm quote,we will need claims paid by month with contracts by month as well as large claims detail at a member level(current status,diagnosis,and prognosis)to within four(4)months of the contract effective date.Data for large claims should be furnished for any claims at 50%or greater of the requested specific stop loss point. Augusta Richmond County ( BlueCross BlueShield Standard ASO 'titif' `� of Georgia Underwriting General Terms and Conditions The services,rates and fees within this proposal are effective from 01/01118 through 12/31/18 Blue Cross Blue Shield of Georgia reserves the right to revise this proposal under any of the following circumstances: • Due to any taxes,fees and assessments prescribed by any statutory,regulatory or other legal authority,that in Blue Cross Blue Shield of Georgia's discretion,invalidates this quote. • Should the employer implement benefit changes that result in substantial changes in the service or networks,as determined by Blue Cross Blue Shield of Georgia • Change in nature of Employers business • Should the total enrollment or enrollment distribution by membership type,product or location change by 10%or more from that assumed when preparing the pricing for this package. • If legislative and/or regulatory changes or mandates materially impact the stop loss policy or the Employers plan documents.Plan documents shall include the documents that set forth the terms of the plan. • Changes in proposal terms,conditions,services or product from this quotation. • The standard reporting package is included in the proposed ASO fee.Non-standard reports may be subject to an additional fee depending on the complexity and frequency requested. • Electronic eligibility or tape feeds must be in a format compatible with BCBSGA systems. • Blue Cross Blue Shield of Georgia's proposal assumes claims incurred prior to the effective date are not included unless specifically noted. • Please note we cannot cover employees who live in Hawaii because we are not an authorized insurer in Hawaii and our benefits generally do not match the requirements of their Prepaid Health Care Act.In order to ensure all state requirements are met,we recommend your broker obtain direct quotes for either individual policies or group coverage from an authorized insurer in Hawaii for your employees who live and work in Hawaii. ' Under final rules issued by EEOC under the Americans with Disabilities Act and Ore Genetic Information Nondiscrimination Act,wellness incentives are subject to certain limits in some situations.Incentive limits may also apply under the Affordable Care Act.Employers are responsible for taking steps to comply with all legally-required incentive limits.Please consult your attorneys or advisors for additional information as needed. Group Specific Caveats • Quote assumes a continuation of the current contribtuion levels for employees and dependents. • Rx is carved out.Fees include$1.65 PCPM for Rx carve-out services. • • A capitation fee will be charged for each Member seeking services from a Provider paid on a capitated basis for Anthem's oversight and care coordination of designated Members.Such capitation fee shall be 20%of the monthly capitation rate paid to Providers. • This quotation assumes the purchase of Blue Cross Blue Shield of Georgia administrated Stop Loss.If Augusta Richmond County chooses to utilize an outside Stop Loss vendor,a coordination charge of$2.00 will apply. • Traditional network provider savings fee.The fee will be equal to 50%of Traditional network discounts.Traditional network discount is the difference between billed charges for covered services and the traditional provider negotiated amount. • Non-network claim discounts.The fee will be equal to 50%of the negotiated savings achieved on certain non-network claims. • Discount Shared Savings:In addition to the per employee monthly fee,a portion of the base administrative services fee will be calculated based on the medical in-network discount savings.Discount shared savings are the difference between billed charges and the negotiated amount paid to a network provider.Employee cost shares will not be impacted.Prescription drugs paid through a pharmacy program and capitated claims are excluded from the fee calculation.Discount Shared Savings will be limited to$5,000 per claim. BCBSGA will provide 20%of Base Fees at risk for Performance Guarantees. Standard Services Included In base admin fee: • Claim Administration • Mailings • Precertification • I.D.Cards • Case Management • Certificate Books • Concurrent Review/Discharge Planning • Local Service • Behavorial Health • Underwriting/Pricing • Network Access • HIPAA certificates • Enrollment meetings • Fiduciary • Enrollment Kits • In the unlikely event the ASO arrangement is terminated by Augusta Richmond County during the implementation phase,the costs incurred by Blue Cross Blue Shield of Georgia to set up and install the group at a charge of one month's worth of Administration fees will be the responsibility of Augusta Richmond County. • This proposal assumes that Blue Cross Blue Shield of Georgia will be the only carrier offered. • Quoted rates are subject to review of audited financial statements and Dun&Bradstreet reports prior to final sale. • Augusta Richmond County must sign the administrative services agreement prior to the effective date,or agree to abide by Blue Cross Blue Shield of Georgia's standard administrative practices until the administrative services agreement is signed.If Augusta Richmond County does not agree to this provision,claims processing could be delayed until an agreement is signed. • If Augusta Richmond County is delinquent in payment for the weekly claims billing,Blue Cross Blue Shield of Georgia will not process further claims until the account is brought current.This applies to both the active period and the 12- month period following termination. • The health benefit plan(s)reflected in this proposal is not considered to be grandfathered under the provisions of the Patient Protection and Affordable Care Act Non-grandfathered plans are subject to additional provisions under the Patient Protection and Affordable Care Act that do not apply to grandfathered plans.For further information,please contact your account representative. • ASO fees and stop loss premiums will be invoiced on the first full week of the month and due within three business days.Claims are billed weekly. • COBRA Administrative services are included. 360°Health Programs: • Blue Cross Blue Shield of Georgia has an extensive suite of 360°Health programs available to clients.Please refer to the proposed fee document for a list of the 3601 Health offerings we are proposing as a tailored solution for Augusta Richmond County. • All CHS Programs included in this quote are illustrated by the rates presented in this document's exhibits. Modifications • The proposal is not accepted in writing within 90 days from its issuance. • The fees assume 2341 contracts.If the actual number of contracts differs by 10%or more,BCBSGA reserves the right to revise the fees. • A change in the contract period will require a recalculation of fees. • Blue Cross Blue Shield of Georgia requires that 75%of Augusta Richmond County's net eligible employees and 50%of total eligible employees enroll in the group sponsored health care program.If Augusta Richmond County contributes 100%of the employee only cost,Blue Cross Blue Shield of Georgia requires that 100%of Augusta Richmond County's net eligible employees and 50%of total eligible employees enroll in the group sponsored health PAM nrewarn • An eligible employee is defined as an active,permanent employee who works for pay or profit at least 30 hours per week,50 weeks per year as of the effective date and who completes the group imposed waiting period. • Blue Cross Blue Shield of Georgia requires that Augusta Richmond County contributes a minimum of 50%of the employee premium for all active and retired employees enrolled in the group health plan. • This quotation for ASO excludes commission. BlueCard Disclosure •The following BlueCard fees will be included in the paid claims amount: o The Access Fee is charged at a percentage no greater than 2.59%of the discount or differential,subject to a maximum of$2,000 per claim. a The AEA Fee is$4.00 per professional provider claim and$9.75 per institutional claim. a The Central Financial Agency Fee is$0.16 per payment notice. a The ITS Transaction Fee is$0.05 per claims transaction. •Occasionally,Anthem and a Host Blue may contract for a lower fee by combining the Access Fees and the AEA Fee. •Some BlueCard fees may not be charged in Anthem states, •BlueCard fees are included in the projected claims costs. igBlueCross BlueShield of Georgia Description of Anthem's Enhanced Personal Health Care Programs' At Anthem Blue Cross and Blue Shield("Anthem"),we believe that our health connects us all.We focus on developing long-term relationships that unite the siloes of healthcare—strengthening the bonds between patients and doctors,primary care providers,specialists,and hospitals—enabling seamless delivery of the right care at the right time. We are committed to connecting our members to patient-centered care.What makes us unique is our approach to supporting delivery system transformation.Anthem incents providers through value-based payment and couples these incentives with a robust support system designed to assist practices in their transformation to patient-centered care. Although there is growing broad-based support for a patient-centered care model,we understand that this shift will not happen spontaneously.Rather,it requires a concerted effort and active support from all key stakeholders in the delivery system to create an environment conducive for change.This includes: • A redesign of current payment models to align financial incentives and to provide compensation for important clinical interventions that occur outside of a traditional patient encounter; • Support for risk-stratified care management; • Sharing meaningful information regarding patients that goes beyond the information captured in the physicians'medical record;and • Providing physicians with the knowledge,information and tools they need to leverage the benefits of new payment models,along with support services and information exchange to help them transform the way they deliver care. Anthem's Enhanced Personal Health Care programs are based on years of experience.Anthem has championed the patient-centered care model through our participation in patient-centered medical home programs across the country.The compelling results we saw in quality improvement and cost of care reduction convinced us to cement our commitment to patient-centered care.In our studies to date,we have observed improvement in compliance with evidence-based guidelines and a reduction in avoidable, unnecessary admissions and ER visits,along with measured maintenance or improvements in the quality of health care services. Our Enhanced Personal Health Care programs are built upon the success of our patient-centered medical home programs and foster a collaborative relationship between Anthem and the contracted Provider.This relationship enables both the health benefits administrator and the Provider to leverage the other party's unique assets whether through clinical,administrative,or data expertise;and together,this partnership supports coordinated care with a focus on risk stratified care management,wellness and prevention,improved access and shared decision-making with patients and their caregivers. We offer this Program Description to give you important information regarding Enhanced Personal Health Care program operations,including the methodology used to charge the employer and details about the reconciliation process.Our intent is to provide you with an easy to understand description of the key elements of the Program. Program Description: • These programs reward Providers(which may include Vendors)for successfully managing the quality and overall health care costs of Anthem members. • These programs pay performance incentives,rewards,or bonuses(including shared savings)to Providers based upon the Providers'achievement of certain cost, quality,efficiency,or service standards and/or metrics. • Some providers may also receive a clinical coordination payment for the clinical services they provide outside of a traditional office visit.Those services could include care planning,maintaining health registries,enhancing access(such as responding to emails or offering web-based visits)or following up with patients via phone or email to make sure that they fill new prescriptions.To participate in the Enhanced Personal Health Care program,Providers must meet consistent value- based criteria,which include,but are not limited to,the following: o 24/7 availability through extended hours and/or after hours call o Participation in our aligned care management and disease management model o Established,dedicated roles within the practice to support this program o Use of the Anthem's Member Medical History Plus(MMH+)system that provides a picture of the services patients may have received outside of the provider's practice o Use of a registry function to effectively manage their patient population and support population health management o Use of generic Rx substitutes where clinically appropriate o Achievement of appropriate performance on nationally-endorsed quality measures o Encouragement of the use of electronic medical records(EMR) o Some larger and/or more sophisticated providers have the capability to take on increased accountability as well as an adequate pool of patients for purposes of the shared savings model.These organizations,which may call themselves accountable care organizations(ACOS)or integrated health systems,are willing to assume the full risk of managing their patients independently,and typically have the following attributes: •a formal legal structure to receive and manage risk sharing; •a well-documented plan for improving patient safety,health status and reducing the cost of medical care; •a commitment to deploying an IT platform,including an electronic medical record and care management solution,supporting the capture, electronic exchange and analysis of clinical information across ambulatory,inpatient and ancillary(lab,imaging,eRx,etc.)settings and sharing key clinical data with Anthem; •the capability to assume a primary role in care planning and care management with support from Anthem resources for more complex patients; •strong physician leadership committed to a patient-centered care model and empowered to drive change across the provider organization. Methodology Used To Charge The Employer: • We use a method we call"attribution"to match members with their providers.The foundation of attribution is to recognize existing provider relationships. o Attribution is used to identify the provider's patient population,defining which members the provider is responsible for and including those members on provider reports. o Attribution is the foundation for clinical coordination payments as well as shared savings calculations and payments. • We use one of two processes for attribution,depending on the type of product in which the member is enrolled: o For products that do not require the selection of a primary care physician(PCP),such as Open Access PPO products,patients are attributed to the Provider they have seen most frequently in a 24-month period based on claims data.In case of a tie,priority will go to the Provider with whom the member has had the longest relationship.Attribution is updated quarterly based on updated claims and reconciled with eligibility each month. o For products that require the selection of a primary care physician,members will be attributed to the provider they select as a primary care physician. The attribution is updated monthly to reflect the selection. • To understand how the Employer is charged,it is helpful to first understand how savings are calculated and how the Provider's share of the savings is determined. o First,we project the expected cost of health care services for attributed members,to establish a Medical Cost Target(MCT),by reviewing risk-adjusted historical claims costs for the Provider or a group of Providers and trending those costs forward.We sometimes group Providers together to ensure that the medical cost target is calculated on the basis of a statistically valid pool of patients. o Then the actual risk-adjusted costs incurred during the year are compared with the medical cost target.If the actual costs are less than the medical cost target and the Provider meets a quality threshold,then the Provider becomes eligible to receive a portion of the savings.If a Provider does not meet the quality threshold,the provider is NOT entitled to any bonus payment,regardless of the savings generated. o If the Provider meets the quality threshold and therefore is eligible to earn a performance bonus,the amount of the bonus will vary based on the Provider's performance on the quality measures.The higher a Provider's quality scores,the larger the bonus the Provider will receive,subject to a maximum payment amount.The expectation is that the Employer will also benefit from the lower overall costs. • Provider performance bonuses are funded by the Employer through a fixed Per Attributed Member Per Month(PaMPM): o This is the amount we actuarially determine to cover the cost of the provider performance bonus. o This amount will be updated periodically based on Anthem's book of business. • A fee shall be charged for Anthem's oversight of Enhanced Personal Health Care with Providers or Vendors.Such fee shall be 25%of the per attributed Member per month amount charged to Employer for the Provider performance bonus portion of the Enhanced Personal Health Care program. Reconciliation Process: • All money collected for the Enhanced Personal Health Care programs will be used only for Enhanced Personal Health Care payments to Providers. • Under the Fixed Per Attributed Member Per Month method,the charge to the Employer will be updated periodically based on experience and actuarial projections.Reconciliation will be completed periodically based on Anthem's self-insured book of business.Any surplus or shortfall will be applied to those forecasts when setting the future payment innovation payment. o Anthem may make additional payments to Providers or Anthem may receive payments from Providers based on the outcome of the measurement period.As a result of these periodic settlements with Providers,Anthem will adjust the fixed Per Attributed Member Per Month to reflect these settlements with Providers.Please note that member cost shares will not be affected by these settlements with Providers. This document is intended to be a description of the Payment Innovation Programs offered by Anthem Blue Cross Blue Shield.This document does not include a description of provider incentive programs offered or administered by the Blue Cross Blue Shield Association or any other Blue Cross and/or Blue Shield Plans. Blue Cross and Blue Shield of Georgia,Inc.and Blue Cross Blue Shield Healthcare Plan of Georgia,Inc.are independent licensees of the Blue Cross and Blue Shield Association.The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 767 IPBlueCross BlueShield of Georgia Description of Blue Distinction Total Care Programs Blue Cross and Blue Shield Plans("The Blues")are fundamentally shifting the way we contract with Providers.We are moving away from traditional fee-for-service contracts that guarantee Provider payment increases,regardless of clinical outcomes.We are instead establishing value-based arrangements that align Provider payments and incentives with demonstrable improvements in quality outcomes and cost efficiency.Blue Distinction Total CareSM is a critical component for this transformation as it supports the alignment of economic incentives to Providers with outcomes,rewarding Providers for clinical interventions that improve the quality and affordability of the health care delivery system. At Blue Cross and Blue Shield of Georgia(BCBSGa),we believe that health care is local,and there is no such thing as"one health fits all."We are the only health plan able to combine local market presence with national scope,and our history of collaborating alongside Providers in the communities we serve affords us the perspective and flexibility to tailor our programming across local and regional differences. Blue Distinction Total CareSM brings together local Blue Plan initiatives,such as BCBSGa's Enhanced Personal Health Care,to deliver a national value-based care solution to our clients and members.Members will be attributed to the local Blue Distinction Total CareSM practices,based on the member's place of residence.All Blue Distinction Total CaresM attributed members receive the benefits offered by the local patient-centered,value-based program. We offer this Program Description to give you important information regarding Blue Distinction Total CareSM program operations,including the methodology used to charge the employer and details about the reconciliation process. Our intent is to provide you with an easy to understand description of the key elements of the programs. Program Description: • These programs consist of Accountable Care Organizations,Global Payment/Total Cost of Care arrangements,Patient Centered Medical Homes,and Shared Savings arrangements. • These programs reward Providers for successfully managing the quality and overall health care costs of BCBSGa members. • These programs pay performance incentives,rewards,or bonuses(including shared savings)to Providers based upon the Providers'achievement of certain cost, quality,efficiency,or service standards and/or metrics. Methodology Used To Charge The Employer: • We use a method called"attribution"to match members with Providers. The purpose of attribution is to recognize and support existing member/Provider relationships o Attribution is used to identify the Provider's patient population,defining which members the Provider is responsible for,so that we can create reports to show Providers how they are performing in the program. • Blue Distinction Total CareSM programs are designed to reflect the local Provider marketplace dynamics;and as a result,the attribution algorithm that aligns members with Providers may vary somewhat by geography and Blue Plan. The following are examples of attribution methodology: o For products that require the selection of a Primary Care Provider("PCP"),members will be attributed to the Provider they select as a PCP. The attribution is updated monthly to reflect the selection. o For products that do not require the selection of a PCP,such as Open Access PPO products,members are attributed to the Provider they have seen most frequently in a 24-month period based on claims data. In case of a tie,priority will go to the Provider with whom the member has had the longest o Although not required for open access products,BCBSGa encourages the selection of a PCP. This can be accomplished in three ways:1)employers can complete designations on the Employer Portal;2)members can make their designation on the Consumer Portal;or 3)members may call Customer Service • To understand how the employer is charged,it is helpful to first understand how savings are calculated and how the Provider's share of the savings is determined. While details in methodology may vary by plan,the core principle holds that all Blue Plans reward Blue Distinction Total Cares"Providers for delivering high quality care while managing cost of care goals. Here's an example of one of BCBSGa's Blue Distinction Total Cares"'programs o We first project the expected cost of health care services for attributed members,to establish a medical cost target,by reviewing risk-adjusted historical claims costs for the Provider or a group of Providers and trending those costs forward.We sometimes group Providers together to ensure that the medical cost target is calculated on the basis of a statistically valid pool of patients. o Then,the actual risk-adjusted costs incurred during the year are compared with the medical cost target.If the actual costs are less than the medical cost target and the Provider meets a quality threshold,the Provider becomes eligible to receive a portion of the savings.If a Provider does not meet the quality threshold,the Provider is not entitled to any bonus payment,regardless of the savings generated. o If the Provider meets the quality threshold,and therefore is eligible to earn a performance bonus,the amount of the bonus will vary based on the Provider's performance on the quality measures.The higher a Provider's quality scores,the larger the bonus the Provider will receive,subject to a maximum payment amount. The expectation is that the employer will also benefit from the lower overall costs. • Provider performance bonuses are funded by the employer through one of the following methods: o Fixed Per Attributed Member Per Month(PaMPM):This is the amount we actuarially determine to cover the cost of the Provider performance bonus. Under BCBSGa's Blue Distinction Total Cares"'programs,this amount will be updated periodically using a projection based on each of our states'self- funded book of business. o Enhanced fee schedule:The program incentive is included within the Provider's fee schedule.This will be included in the medical claims expense and will not be detailed on the claims invoice • Member cost share will not be affected by Provider performance payments. Reconciliation Process: • •The Blue Distinction Total Cares" charges to the employer will be updated periodically based on experience and actuarial projections.Reconciliation will be completed periodically and any surplus or shortfall will be applied to those forecasts when setting the future Blue Distinction Total Cares" payments. o For example,BCBSGa may make additional payments to Providers or BCBSGa may receive payments from Providers based on the outcome of the measurement period. As a result of these periodic settlements with Providers based on BCBSGa's self-insured book of business,BCBSGa will adjust the PaMPM amount prospectively to reflect these settlements with Providers o All Blue Distinction Total CareSM charges are reviewed quarterly by the Blue Cross Blue Shield Association. o Please note that member cost shares will not be affected by the reconciliation process. BCBSGa appreciates your support during this exciting time as Provider Payment Innovation evolves and new value streams are created.We are committed to this transformation and early results have shown improvement in both quality outcomes and medical cost containment.Blue Distinction Total CareSM will continue to evolve and lead the way for payment innovation in the marketplace,delivering better health management for your members,and ensuring efficient use of your health care resources. Blue Cross and Blue Shield of Georgia,Inc.and Blue Cross Blue Shield Healthcare Plan of Georgia,Inc.are independent Ikensees of the Blue Cross and Blue Shield Association.The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.