Laserfiche WebLink
the patient such as outpatient, physician, ancillary, hospital services and prescription drugs. <br />Patient -Centered Medical Home (PCMH): A model of care in which each patient has an <br />ongoing relationship with a primary care physician who coordinates a team to take <br />collective responsibility for patient care and, when appropriate, arranges for care with other <br />qualified physicians. <br />Shared Savings: A payment mechanism in which the provider and payer share cost savings <br />achieved against a target cost budget based upon agreed upon terms and may include <br />downside risk. <br />Value -Based Program (VBP): An outcomes -based payment arrangement and/or a <br />coordinated care model facilitated with one or more local providers that is evaluated <br />against cost and quality metrics/factors and is reflected in provider payment. <br />Value -Based Programs Overview <br />Employer's members may access covered healthcare services from providers that <br />participate in a Host Blue's Value -Based Program. Value -Based Programs may be <br />delivered either through the B1ueCard Program or a Negotiated Arrangement. These <br />Value -Based Programs may include, but are not limited to, Accountable Care <br />Organizations, Global Payment/Total Cost of Care arrangements, Patient Centered <br />Medical Homes and Shared Savings arrangements. <br />Value -Based Programs under the BlueCard Program <br />Under Value -Based Programs, a Host Blue may pay providers for reaching agreed upon <br />cost/quality goals in the following ways: <br />The Host Blue may pass these provider payments to BCBSF and/or its Designated Agent, <br />which BCBSF and/or its Designated Agent will pass directly on to Employer as either an <br />amount included in the price of the claim or an amount charged separately in addition to <br />the claim. <br />When such amounts are included in the price of the claim, the claim may be billed using <br />one of the following pricing methods, as determined by the Host Blue: <br />(i) Actual Pricing: The charge to accounts for Value -Based Programs <br />incentives/Shared Savings settlements is part of the claim. These charges are <br />passed to Employer via an enhanced provider fee schedule. <br />(ii) Supplemental Factor: The charge to accounts for Value -Based Programs <br />incentives/Shared Savings settlements is a supplemental amount that is included <br />in the claim as an amount based on a specified supplemental factor (e.g., a small <br />percentage increase in the claim amount). The supplemental factor may be <br />adjusted from time to time. <br />When such amounts are billed separately from the price of the claim, they may be <br />billed as follows: <br />• Per Member Per Month (PMPM) Billings: Per member per month billings for <br />32 <br />