Assumptions and conditions (ABF) Zoe Center for Pediatric and Adolescent Health LLC
Effective June 1, 2025 through May 31, 2026
SIC Code: 8011
Anthem Balanced Funding (ABF) - The Specific Stop-Loss level reflects accumulation on a per member basis.
The Employer shall pay the Monthly Claims Funding amount during the policy period. Settlement will occur at the end of the policy period in accordance with the agreement. Surpluses, to the extent they exist, will be returned thereafter. Regardless of settlement calculation, Anthem will guarantee a Surplus of $15,000 for this contract year. Please refer to our specimen ABF and Stop-Loss Agreements for complete details. - Anthem reserves the right to inspect and audit any and all Employer documents relating to claims submitted to Anthem. Documentation includes, but is not limited to, claims, case management, utilization management records, audit records (including audits of TPA and TPA's providers and vendors), eligibility, as well as other information requested by Anthem. Anthem also has the right to review and audit records related to subrogation and other recoveries. • Anthem Balanced Funding Affordable Care Act: - The Patient-Centered Outcomes Research Trust Fund fee is a fee on issuers of specified health insurance policies and plan sponsors of applicable self- insured health plans that helps to fund the Patient-Centered Outcomes Research Institute (PCORI). The proposed rates do not include the PCORI fee, since it is assumed the employer will remit payment to HHS directly. • Description of Blue Distinction Total Care Programs (known locally as Enhanced Personal Health Care) - 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 Care(SM) 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 Anthem, 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 Care(SM) brings together local Blue Plan initiatives, such as Anthem'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 Care(SM) practices, based on the member's place of residence. All Blue Distinction Total Care(SM) 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 Care(SM) 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 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. • 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. - Attribution is used to identify the Provider's patient population, defining which members the Provider is responsible for, so that we create reports to show Providers how they are performing in the program.
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