2010-06-07_(2).pdf - 19318.8K - BridgeportCT.gov

CIGNA HealthCare Performance Guarantee Agreement
Customer Bridgeport City BOE
Effective Date July 1 2010
Account Number s involved in Performance Guarantee s 3213172
IIr
CIGNA
EXHIBIT B4
CLINICAL
1 Additional Definitions
11 Baseline Period Means the twelve 12
month incurred period immediately prior
to effective date ofthepertinent Disease
Management Program Connecticut
General reserves the right to re establish
the baseline period if it is deemed to be
too historical
1 2 Case Management Program
Connecticut General case management or
utilization management program
including complex specialty and
catastrophic case management and
utilization management programs
13 Client Specific Connecticut General s
performance is measured as to
Employer s Participants not the CIGNA
BookofBusiness
14 Claim Costs for Client Specific Means
all fee for service and fee for service
equivalents for capitated encounter data
health care costs including all pharmacy
costs
incurred under Employer s
applicable Plan s for Covered Services
provided Participants during the
applicable measurement period i e
Baseline Period or Guarantee Period
capped at 100 000 per Participant
Claims Costs do not include any
Participant co payments coinsurance or
deductible amounts or any Well A ware
Program charges paid by the Employer
For purposes
ofthis definition a cost is
incurred on the datethat a Covered
Service is provided to a Participant not
the date the Plan pays the cost
15 Core 5 Well Aware The Core 5 Well
Aware programs are
Asthma Disease
Management Program Chronic
Obstructive Pulmonary Disease COP D
Disease Management Program Diabetes
Disease Management Program Heart
Disease Management Program Low
Back Pain Disease Management
1 6 Covered Services for Client Specific
Means health care including pharmacy
services and or supplies that are covered
under Employer s applicable Plans
1 7 Disease ManagementMaximum The
maximum Payment Amount that applies
ifnone ofthe Disease Management
Guarantees are met during the Guarantee
Period
The exposure is determined on a
pro rata basis for this measure For
example if the Guarantee Period results
are 90 ofthe target results then only
10 ofthe fees at risk will be paid or
credited to Employer
1 8 Documented Care Plan A documented
plan for a complex catastrophic and
specialty intensilty case management case
where there is documented verbal consent
from the Plan PElrticipant for case
management services and where the plan
at aminimum identifies one 1 short
term goal oneI long term goal and one
1 exit goal
1 9 ETG Stands for Episode Treatment
Group a methodology developed by
Symmetry Health and used for measuring
compliance with the Pharmacy
guarantees
1l0 HEDIS Measure Rotation
Shall be
defmed as Connecticut General s use of
the audited and reportable rate from the
prior year s data collection in lieu of
collecting the measure for the Guarantee
Period based on NCQA approved
methodology
1 II Medical Management Full Program
Means the full array ofConnecticut
OS 28 2010
2010 Performance Guarantee Page 22