10. Managed Care Arrangements
A. Price reductions offered by a contract health provider to a health plan pursuant to a written agreement between the parties, provided:
1. the term of the agreement is not less than one year;
2. the agreement specifies the items and services covered;
3. fee schedule remains in effect throughout term;
4. no claims to Medicare or Medicaid in excess of fee schedule;
5. price reductions are reported on cost report;
6. no claims to Medicare or Medicaid by contract health providers under health plan.
B. Financial arrangements (involving price reductions) between an Eligible Managed Care Organization (“EMCO”) and any of its direct contracting providers, and also any of their next tier “downstream” direct contracting sub-providers, pursuant to a written agreement between the EMCO and provider or provider and sub-provider, provided standards corresponding to those in A. above are satisfied.
C. Price reductions offered by contract health provider (and/or sub-contractors) with “substantial financial risk” to Qualified Managed Care Plan (“QMCP”), provided standards corresponding to those in A. and B. above are satisfied. “Substantial financial risk” is defined in two ways, i.e., by payment methodology (e.g., capitation, percentage of premium and DRG payments, etc.), and by a numeric standard (i.e., if a certain percentage of the provider’s compensation is subject to withhold.)
D. Increased coverage, reduced cost-sharing amounts, or reduced premium amounts offered by health plans to enrollees, provided the plan complies with certain specified standards.
Anti-Kickback Safe Harbor
Sources: 42 U.S.C. § 1320a-7b(b)(3)(F), 42 C.F.R. § 1001.952(m), 42 C.F.R. § 1001.952(t), 42 C.F.R. § 1001.952(u), and 42 C.F.R. § 1001.952(l)