HomeMy WebLinkAboutAgreement A-25-576 with Anthem Blue Cross.pdf Agreement No. 25-576
HEALTH PLAN-PROVIDER AGREEMENT
AGREEMENT TO IMPLEMENT THE CALENDAR YEAR 2024 RATE RANGE IGTS
This Agreement is effective January 1, 2024 ("Effective Date")between Blue
Cross of California dba Anthem Blue Cross, a California corporation hereinafter referred to as
"PLAN", and County of Fresno, by and through the Department of Public Health, hereinafter
referred to as "PROVIDER."
RECITALS:
WHEREAS, PLAN is licensed under Health and Safety Code Section 1349 et seq.
has a contract with the State Department of Health Care Services pursuant to Welfare and
Institutions Code Section 14087.3 to act as a Medi-Cal managed care plan to fulfill its
responsibilities for the provision of Medi-Cal covered services for eligible Medi-Cal members.
WHEREAS, PROVIDER is organized and operating under the laws of the State
of California and possesses any and all licenses and/or governmental approvals required in order
for it to provide public health services and is qualified to provide such services. Provider and
Plan have entered into a separate Agreement under which PROVIDER arranged for the provision
of services to certain Medi-Cal managed care enrollees. For valuable consideration exchanged,
the sufficiency of which the parties hereby acknowledge, the parties wish to take this opportunity
to provide for supplemental compensation to PROVIDER for services it arranged for and
provided while that Agreement was in force, as explained in the next paragraph; and
WHEREAS, PLAN and PROVIDER desire to enter into an Agreement to provide
for Medi-Cal managed care capitation rate increases to PLAN as a result of intergovernmental
transfers ("IGTs") from County of Fresno (GOVERNMENTAL FUNDING ENTITY)to the
California Department of Health Care Services ("State DHCS")to maintain the availability of
Medi-Cal health care services to Medi-Cal beneficiaries.
NOW, THEREFORE, PLAN and PROVIDER hereby agree as follows:
2024 IGT MEDI-CAL MANAGED CARE CAPITATION RATE RANGE INCREASES
1. IGT Capitation Rate Range Increases to PLAN
A. Payment
Should PLAN receive any Medi-Cal managed care capitation rate increases from
State DHCS where the nonfederal share is funded by the GOVERNMENTAL FUNDING
ENTITY specifically pursuant to the provisions of the Intergovernmental Agreement Regarding
Transfer of Public Funds, #24-0032, ("Intergovernmental Agreement") effective for the period of
January 1, 2024 through December 31, 2024 for Intergovernmental Transfer Medi-Cal Managed
Care Rate Range Increases ("IGT MMCRRIs"), PLAN shall pay to PROVIDER the amount of
the IGT MMCRRIs received from State DHCS, in accordance with paragraph LE below
Health Plan-Provider Agreement, County of Fresno and Anthem, 2024 VRRP
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regarding the form and timing of Local Medi-Cal Managed Care Rate Range ("LMMCRR") IGT
Payments. LMMCRR IGT Payments paid to PROVIDER shall not replace or supplant any other
amounts paid or payable to PROVIDER by PLAN.
B. Health Plan Retention
(1) The PLAN shall retain a two and a half percent(2.5%) administrative fee
based on the total amount of the IGT MMCRRIs received from DHCS for PLAN's cost to
administer this program. Each provider's share of the 2.5% fee shall be calculated based on that
provider's proportionate share of the LMMCRR IGT payment made by PLAN in Fresno County.
(2) PLAN will not retain any other portion of the IGT MMCRRIs received
from the State DHCS other than those mentioned above.
C. Conditions for Receiving Local Medi-Cal Managed Care Rate Range IGT
Payments
As a condition for receiving LMMCRR IGT Payments, PROVIDER shall, as of
the date the particular LMMCRR IGT Payment is due:
(1) Remain a participating PLAN provider;
(2) Remain a participating provider of medical diagnostic, treatment, and care
management services for PLAN Medi-Cal beneficiaries.
D. Schedule and Notice of Transfer of Non-Federal Funds
PROVIDER shall provide PLAN with a copy of the schedule regarding the
transfer of funds to State DHCS, referred to in the Intergovernmental Agreement, within fifteen
(15) calendar days of the PROVIDER establishing such schedule with the State DHCS.
Additionally, PROVIDER shall notify PLAN, in writing, no less than seven(7) calendar days
prior to any changes to an existing schedule including, but not limited to, changes in the amounts
specified therein.
E. Form and Timing of Payments
PLAN agrees to pay LMMCRR IGT Payments to PROVIDER in the following
form and according to the following schedule:
(1) PLAN agrees to pay the LMMCRR IGT Payments to PROVIDER using
Health Plan-Provider Agreement, County of Fresno and Anthem, 2024 VRRP
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the same mechanism through which compensation and payments are normally paid to
PROVIDER(e.g., electronic transfer). After paying any required taxes and retaining the PLAN's
administrative fee, as shown in Section B above, PLAN will pay PROVIDER a percent of the
remaining LMMCRR IGT payment equal to the PROVIDER's contribution as a percent of total
local provider contributions.
(2) PLAN will pay the LMMCRR IGT Payments to PROVIDER no later than
sixty(60) calendar days after receipt of the IGT MMCRRIs from State DHCS.
F. Consideration
(1) As consideration for the LMMCRR IGT Payments, PROVIDER shall
use the LMMCRR IGT Payments for the following purposes and shall treat the LMMCRR IGT
Payments in the following manner:
(a) The LMMCRR IGT Payments shall represent compensation for
Medi-Cal services rendered to Medi-Cal PLAN members by PROVIDER during the State
calendar year to which the LMMCRR IGT Payments apply.
(b) To the extent that total payments received by PROVIDER for any
State calendar year under this Agreement exceed the cost of Medi-Cal services provided to
Medi-Cal beneficiaries by PROVIDER during that calendar year, any remaining LMMCRR IGT
Payment amounts shall be retained by PROVIDER to be expended for health care services.
Retained LMMCRR IGT Payment amounts may be used by the PROVIDER in either the State
calendar year for which the payments are received or subsequent State calendar years.
(2) For purposes of subsection(1) (b) above, if the retained LMMCRR IGT
Payments, if any, are not used by PROVIDER in the State calendar year received, retention of
funds by PROVIDER will be established by demonstrating that the retained earnings account of
PROVIDER at the end of any State calendar year in which it received payments based on
LMMCRR IGT Payments funded pursuant to the Intergovernmental Agreement, has increased
over the unspent portion of the prior State calendar year's balance by the amount of LMMCRR
IGT Payments received, but not used. These retained PROVIDER funds may be commingled
with other GOVERNMENTAL FUNDING ENTITY funds for cash management purposes
provided that such funds are appropriately tracked and only the depositing facility is authorized
to expend them.
(3) Both parties agree that none of these funds, either from the
GOVERNMENTAL FUNDING ENTITY or federal matching funds will be recycled back to the
GOVERNMENTAL FUNDING ENTITY'S general fund, the State, or any other intermediary
organization. Payments made by the health plan to providers under the terms of this Agreement
constitute patient care revenues.
G. PLAN's Oversight Responsibilities
Health Plan-Provider Agreement, County of Fresno and Anthem, 2024 VRRP
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PLAN's oversight responsibilities regarding PROVIDER's use of the LMMCRR
IGT Payments shall be limited as described in this paragraph. PLAN may request, within thirty
(30) calendar days after the end of each State calendar year in which LMMCRR IGT Payments
were transferred to PROVIDER, a written confirmation that states whether and how PROVIDER
complied with the provisions set forth in Paragraph LF above. In each instance, PROVIDER
shall provide PLAN with written confirmation of compliance within thirty(30) calendar days of
PLAN's request.
H. Cooperation Among Parties
Should disputes or disagreements arise regarding the ultimate computation or
appropriateness of any aspect of the LMMCRR IGT Payments, PROVIDER and PLAN agree to
work together in all respects to support and preserve the LMMCRR IGT Payments to the full
extent possible on behalf of the safety net in Fresno County.
L Reconciliation
Within one hundred twenty(120) calendar days after the end of each of PLAN's
fiscal years in which LMMCRR IGT Payments were made to PROVIDER, PLAN shall perform
a reconciliation of the LMMCRR IGT Payments transmitted to the PROVIDER during the
preceding fiscal year to ensure that the supporting amount of IGT MMCRRIs were received by
PLAN from State DHCS. PROVIDER agrees to return to PLAN any overpayment of LMMCRR
IGT Payments made in error to PROVIDER within thirty(30) calendar days after receipt from
PLAN of a written notice of the overpayment error unless PROVIDER submits a written
objection to PLAN. Any such objection shall be resolved in accordance with the dispute
resolution processes set forth in Section H. of this Agreement or otherwise in good faith by the
parties. The reconciliation processes established under this paragraph are distinct from the
indemnification provisions set forth in Section J. below. PLAN agrees to transmit to the
PROVIDER any underpayment of LMMCRR IGT Payments within thirty (30) calendar days of
PLAN's identification of such underpayment.
J. Indemnification
PROVIDER agrees to indemnify and hold PLAN harmless in all matters
relating to the IGT request, subsequent payment and use of such funds.
K. Remittance Information
The IGT-funded payments made by the PLAN pursuant only to this Agreement,
shall be mailed to the PROVIDER at the address set forth below:
Attention: Irene Parada
Finance Division Manager
Health Plan-Provider Agreement, County of Fresno and Anthem, 2024 VRRP
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County of Fresno Department of Public Health
1221 Fulton Street
Fresno, CA 93721
Phone: (559) 600-6438
Email: i ap radagfresnocountyca.gov
2. Term
The term of this Agreement shall commence on January 1, 2024, and shall
terminate on December 31, 2027.
SIGNATURES
BY PLAN:
Date: 10/14/2025
John Pickett, Regional Vice President,Provider Solutions
BY PROVIDER: Date:
Ernest Buddy Mendes, Chairman of the Board of Supervisors of the County of Fresno
ATTEST:
BERNICE E.SEIDEL
Clerk of the Board of Supervisors
County of Fresno,State of California
By_ Deputy
Health Plan-Provider Agreement, County of Fresno and Anthem,2024 VRRP
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