April 2017 MCO List Template

  • Template is also available in Excel format (XLSX)


Background: By the beginning of DY4 (4/1/18), all participating VBP QIP Facilities must have entered into managed care contracts where 80% of the total Medicaid payments from Medicaid MCOs to Facility (across all contracts) are tied to VBP components (Level 1 or higher). The main way a facility will reach the target of having 80% of the total Medicaid payments from Medicaid MCOs tied to VBP components will be through entering into VBP TCGP arrangements.

Purpose: The purpose of this template is to (1) provide each VBP QIP facility with a tool to evaluate and assess where there are opportunities for transitioning services to VBP TCGP arrangements; (2) collect information on each MCO that the VBP QIP Facility is currently contracted with as well as measure what percentage of those contract payments are part of value–based arrangements, and (3) assist the Department of Health (DOH) in evaluating each Facility's progress in VBP Contracting.

This spreadsheet lays out a template for listing all current MCOs with which a facility has Medicaid Managed Care contracts and listing each contract's respective values. The spreadsheet also provides for a calculation of the VBP threshold percentage. This template must be filled out and submitted to DOH through the vbp–qip mailbox (vbp_qip@health.ny.gov) by no later than April 1, 2017. The Department will not disclose any contract information provided to any external parties.

Please follow the instructions provided in the next tab to complete the assessment.


Item Number Description
(1) Facility Name Provide Facility's Legal Name.
(2) Submission Date Provide the current date of submission. This will be important to distinguish from future updates you may provide.
(3) Overall Calculated VBP Threshold Automated calculation, no input required. If the threshold does not reach 80%, it will reflect the number in red . If it is 80% or more, it will reflect the number in green .
(4) MCO Name Provide the names of the MCOs you have Medicaid Managed Care contracts with. Please list all MCOs with which you have a contract in place - there is additional space in the spreadsheet if needed. All contracted MCOs must be listed to accurately account for the total dollars associated with all MCO contracts (the denominator for the threshold percentage calculation) that you receive.
(5) 2015 Total MCO Medicaid Contract Payments ($) For the April 1st P4R submission, please identify the calendar year (CY) 2015 total MCO contract payment dollars you received for any MCOs that you listed in Item 4 that pertain to your facility. For the July 1st P4R submission, facilities will be expected to update this document with contract payments to reflect CY 2016 data.
(6) Is this service covered under a TCGP VBP Arrangement? From the drop down menu, select "yes" if this contract meets a Level 1 or higher TCGP VBP arrangement or "no" if it doesn't. This applies only to TCGP arrangements and you should select "no" if this contract is for any VBP arrangement other than TCGP. The Managed Care Division of the Department of Health will subsequently confirm that services marked "yes" are covered under a managed care contract that DOH has on file.
(7) Risk Level From the drop down menu select the specific level of risk taken for this service within the contract. Select FFS (fee for service) if no risk is assumed.
(8) Total $ in at least Level 1 TCGP VBP Arrangement by April 1, 2018 No input is needed here. If this service is covered by a VBP arrangement and Item 6 is marked as 'Yes', the amount provided in (8) Total Medicaid Payments will automatically duplicate. If you answered "NO" in Item 6, no dollars payment will be posted. Please do not enter or delete any values from this column.
(9) Subtotal of All MCO Contract $ Automated calculation, no input required.
(10) Total VBP $ in MCO Contracts Automated calculation, no input required.

(1) Facilty Name: [Name]
(2) Submission Date: [mm/dd/yyyy]
(3) Overall Calculated VBP Threshold: 91%

(4) List of MCOs with Medicaid
Managed Care Contracts
(5) CY 2015 Total MCO
Contract Payments ($)
(6) Is the contract with this
MCO currently or expected
to be covered under a Level
1 (or higher) TCGP VBP
Arrangement by April 1,
(7) VBP
Risk Level
(8) Projected Managed
Care Contract Dollars
(using CY 2015 data) to be
in at least a Level 1 TCGP
VBP Arrangement by April 1,
MCO 10
Level 1
Level 1
FFS (non–VBP)
(9) Subtotal of All MCO Contract $ $16,000,000   (10) Total VBP $ in MCO Contracts 14,500,000