VBP QIP MCO Contract Attestation

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Submission Guidelines

For the DY4 Pay for Reporting (P4R) deliverable, each Facility participating in the Value Based Purchasing Quality Improvement Program (VBP QIP) was expected to sign contracts which were submitted to the Department of Health totaling at least 80% of all Medicaid Managed Care dollars in a Value Based Payment arrangement based on 2016 Medicaid Managed Care revenue. Please note, if your facility submitted a Service Exclusion Waiver, only dollars associated with Inpatient Services and Emergency Room Visits were used in the aforementioned calculation. Attestations were signed by an authorized senior financial officer at the Facility, confirming the accuracy of the data provided in the document.

For the DY5 P4R deliverable, Facilities must comply with DY4 P4R requirement and maintain 80% of all Medicaid Managed Care dollars in VBP arrangements through DY5. This attestation confirms that your facility will remain in these arrangements at a minimum through the end of the program, March 31, 2020.

VBP QIP Facilities must submit this attestation to the NYS DOH for record keeping to: vbp_qip@health.ny.gov with "VBP QIP – MCO Contract Attestation" in the subject line.


I, _____(Name)________________, employed by ______(Facility Name) ___________, as ________(Title)___________, hereby attest that the signed contracts submitted as part of the VBP QIP, have been reviewed, deemed accurate, and satisfy the VBP QIP Pay-for-Reporting requirement of at least 80% of relevant Medicaid Managed Care dollars for your facility tied to a Value Based Payment arrangement through the conclusion of the program in March of 2020.

Your facility has entered into Value Based Payment arrangements with the following MCOs (click all that apply):

Name of MCO Contract in Place
Affinity Health Plan, Inc.
Amida Care, Inc.
Capital District Physician's Health Plan, Inc.
Crystal Run Health Plan, LLC
Excellus Health Plan, Inc.
Health Insurance Plan of Greater New York, Inc.
Healthfirst PHSP, Inc.
HealthNow of New York, Inc.
HealthPlus HP, LLC
Independent Health Association, Inc.
Molina Healthcare of New York, Inc.
MetroPlus Health Plan, Inc.
MVP Health Plan, Inc.
New York Quality Healthcare Corporation (Fidelis)
VNS (D/b/a VNSNY Choice) and Subsidiary
WellCare of New York, Inc.
UnitedHealthcare of New York Inc.
YourCare Health Plan, Inc.

Date: _______________________________

Authorizing Signature: _______________________________