Contract Provisions for the Hawaii QUEST Expanded Access Risk Share Program Not Implemented

摘要

The QUEST Expanded Access risk share program (referenced in RFP-MQD-2008-006, Appendix B) was required to be implemented on February 1, 2009. The objective of the risk share program is to address the risk of a significant difference between total revenue (capitated payments) received by the health plans for delivery of health care services and the aggregate health care expenses of the plans. Specifically, the established capitation rates may not be appropriate for the health services provided to the enrolled population. Under the risk share program, the State agency shares in any significant difference between the capitated payments and the actual net health care expenditures of the health plans. The plans are required to submit annual financial reports within 45 days of the annual reporting period ended June 30, the States fiscal yearend. However, because some of the data may not be available within the 45-day period, the State agency will request that the plans submit updated financial reports for the fiscal year ended June 30 for any adjustments through December 31. The updated financial reports are due to the State agency by January 15. Upon receiving the updated annual financial reports, the State agency is required to develop an aggregate profit-and-loss statement and to compute a net loss or gain percentage based on the total capitated payments to the health plans. The State agency uses this information to determine whether the risk sharing provisions of the contract are applicable. Our objective was to determine whether the State agency properly implemented the contract provisions for the QUEST Expanded Access risk share program.