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) - Blue Distinction Total Care(SM) programs are designed to reflect the local Provider marketplace dynamics; and as a result, the attribution algorithm that aligns members with Providers may vary somewhat by geography and Blue Plan. The following are examples of attribution methodology: ° For products that require the selection of a Primary Care Provider ("PCP"), members will be attributed to the Provider they select as a PCP. The attribution is updated monthly to reflect the selection. ° For products that do not require the selection of a PCP, such as Open Access PPO products, members are attributed to the Provider they have seen most frequently in a 24-month period based on claims data. In case of a tie, priority will go to the Provider with whom the member has had the longest relationship. Attribution is updated quarterly based on updated claims and reconciled with eligibility each month. ° Although not required for open access products, Anthem encourages the selection of a PCP. This can be accomplished in three ways: 1) employers can complete designations on the Employer Portal; 2) members can make their designation on the Consumer Portal; or 3) members may call Customer Service. - To understand how the employer is charged, it is helpful to first understand how savings are calculated and how the Provider's share of the savings is determined. While details in methodology may vary by plan, the core principle holds that all Blue Plans reward Blue Distinction Total Care(SM) Providers for delivering high quality care while managing cost of care goals. Here's an example of one of Anthem's Blue Distinction Total Care(SM) programs: ° We first project the expected cost of health care services for attributed members, to establish a medical cost target, by reviewing risk-adjusted historical claims costs for the Provider or a group of Providers and trending those costs forward. We sometimes group Providers together to ensure that the medical cost target is calculated on the basis of a statistically valid pool of patients. ° Then, the actual risk-adjusted costs incurred during the year are compared with the medical cost target. If the actual costs are less than the medical cost target and the Provider meets a quality threshold, the Provider becomes eligible to receive a portion of the savings. If a Provider does not meet the quality threshold, the Provider is not entitled to any bonus payment, regardless of the savings generated. ° If the Provider meets the quality threshold, and therefore is eligible to earn a performance bonus, the amount of the bonus will vary based on the Provider's performance on the quality measures. The higher a Provider's quality scores, the larger the bonus the Provider will receive, subject to a maximum - Fixed Per Attributed Member Per Month (PaMPM): This is the amount we actuarially determine to cover the cost of the Provider performance bonus. Under Anthem's Blue Distinction Total Care(SM) programs, this amount will be updated periodically using a projection based on each Anthem states' self-funded book of business. - Enhanced fee schedule: The program incentive is included within the Provider's fee schedule. This will be included in the medical claims expense and will not be detailed on the claims invoice. - Member cost share will not be affected by Provider performance payments. • Reconciliation Process: - The Blue Distinction Total Care(SM) charges to the employer will be updated periodically based on experience and actuarial projections. Reconciliation will be completed periodically and any surplus or shortfall will be applied to those forecasts when setting the future Blue Distinction Total Care(SM) payments - For example, Anthem may make additional payments to Providers or Anthem may receive payments from Providers based on the outcome of the measurement period. As a result of these periodic settlements with Providers based on Anthem's self-insured book of business, Anthem will adjust the PaMPM amount prospectively to reflect these settlements with Providers. - All Blue Distinction Total Care(SM) charges are reviewed quarterly by the Blue Cross Blue Shield Association. payment amount. The expectation is that the employer will also benefit from the lower overall costs. • Provider performance bonuses are funded by the employer through one of the following methods:
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