VBP Contract Attestation

Submission Guidelines

  • Attestation is also available in Portable Document Format (PDF)

Each Facility participating in the Value Based Purchasing Quality Improvement Program (VBP QIP) is expected to sign contracts which will be 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 will be used in the aforementioned calculation. Attestations must be signed by an authorized senior financial officer at the Facility, confirming the accuracy of the data provided in the document.v

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, , employed by , as , 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.

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

Name of MCO Contracts Submitted
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 State Catholic Health Plan, Inc (Fidelis)
VNS (D/b/a VNSNY Choice) and Subsidiary
WellCare of New York, Inc.
UnitedHealthcare of New York Inc.
YourCare Health Plan, Inc.


Authorizing Signature: