SFY 2026 Cardinal Care Performance Withhold Program Methodology

CMS Adult Core Set measures to DMAS. Only measure/indicator rates with a “Reportable (R)” (HEDIS and non-HEDIS rates) audit result (i.e., the plan produced a reportable rate for the measure/indicator in alignment with the technical specifications) will be included in the PWP calculation. Measure/indicator rates with a “Small Denominator (NA)” (HEDIS rates only) status (i.e., the plan followed the specifications, but the denominator was too small to report a valid rate) will be excluded from the PWP calculation. Measure/indicator rates with any result other than a “Reportable (R)” audit result or “Small Denominator (NA)” status will receive a score of zero (i.e., the MCO will not be eligible to earn a portion of the quality withhold back for that measure). SFY 2026 PWP The SFY 2026 PWP will use the MCOs’ audited HEDIS MY 2025 and validated CY 2025 AHRQ PDI and CMS FFY 2026 CMS Adult Core Set performance measure data. Table 2 shows the percentage of the withhold associated with each domain. 3 Per the AHRQ technical measure specifications, the Asthma Admission Rate is reported per 100,000 members age 2 to 17. Available at: https://qualityindicators.ahrq.gov/Downloads/Modules/PDI/V2025/TechSpecs/PDI_14_Asthma_Admission_Rat e.pdf However, this measure should be reported to DMAS per 100,000 MM for members age 2 to 17. This slight deviation is needed to align with the approach for reporting in CMS’ Adult Core Set. 4 Department of Health and Human Services, Centers for Medicare and Medicaid Services. CMS External Quality Review (EQR) Protocols, February 2023. Available at: https://www.medicaid.gov/medicaid/quality-of- care/downloads/2023-eqr-protocols.pdf. Accessed on: Sep 3, 2024. SFY 2026 CARDINAL CARE PWP METHODOLOGY SFY 2026 Cardinal Care Performance Withhold Program Methodology Page 4 Commonwealth of Virginia SFY 2026 Cardinal Care Performance Withhold Program Methodology_F1_1025 Table 2— SFY 2026 PWP Domain Weights Domain Measure/Indicator Domain Weight 1 Asthma Admission Rate (per 100,000 MM)* 10% 2 Child and Adolescent Well-Care Visits—Total 10% 3 Childhood Immunization Status—Combination 3 10% 4 COPD or Asthma in Older Adults Admission Rate (per 100,000 MM)—Total* 10% 5 Comprehensive Diabetes Care Composite (3 measures) – Blood Pressure Control for Patients With Diabetes—Total – Eye Exam for Patients With Diabetes— Total – Glycemic Status Assessment for Patients With Diabetes (2 Indicators) • Glycemic Status <8.0%—Total • Glycemic Status >9.0%—Total* 10% 6 Follow-Up After ED Visit for Substance Use (2 Indicators) • 7-Day Follow-Up—Total • 30-Day Follow-Up—Total 10% 7 Follow-Up After ED Visit for Mental Illness (2 Indicators) • 7-Day Follow-Up—Total • 30-Day Follow-Up—Total 10% 8 Heart Failure Admission Rate (per 100,000 MM)—Total* 10% 9 Initiation and Engagement of SUD Treatment (2 Indicators) • Initiation of SUD Treatment—Total • Engagement of SUD Treatment—Total 10% 10 Prenatal and Postpartum Care (2 Indicators) • Timeliness of Prenatal Care—Total • Postpartum Care—Total 10% *For this measure/indicator, a lower rate indicates better performance. SFY 2026 CARDINAL CARE PWP METHODOLOGY SFY 2026 Cardinal Care Performance Withhold Program Methodology Page 5 Commonwealth of Virginia SFY 2026 Cardinal Care Performance Withhold Program Methodology_F1_1025 Scoring Methods The next several sections describe the PWP calculation method for the SFY 2026 PWP. Measure/Indicator Partial Score For SFY 2026, the AHRQ PDI and CMS Adult Core Set measure scoring will be based on whether the MCO reported valid CY 2025 measure rates in the required reporting method as indicated in Table 3. As indicated in Table 3, only measures with a “Reportable (R)” audit result (i.e., the plan produced a reportable rate for the measure in alignment with the technical specifications) will be included in the PWP calculation for the AHRQ PDI and CMS Adult Core Set measures. Measure rates with the following audit results will receive a score of zero (i.e., the MCO will not be eligible to earn a portion of the quality withhold back for that measure): • “Do Not Report (DNR)” audit result (i.e., the calculated rate was materially biased) • “Not Applicable (NA)” audit result (i.e., the plan was not required to report the measure) • “No Benefit (NR)” audit result (i.e., the measure was not reported because the plan did not offer the required benefit) Table 3—Audit Designations (AHRQ PDI and CMS Adult Core Set) Audit Designation Eligible for Points Ineligible for Points Reportable (R) Do Not Report (DNR) Not Applicable (NA) No Benefit (NR) The performance scores for the HEDIS measures/indicators will be determined by comparing each rate to NCQA’s Quality Compass ®5 national Medicaid health maintenance organization (HMO) percentiles (referred to in this document as percentiles).Table 4 presents the possible scores for each HEDIS measure/indicator based on the MCO performance for the current year. Rates will be rounded to two decimals prior to comparing to the percentiles and determining the measure/indicator score, and no scores will be dropped. 5 Quality Compass ® is a registered trademark of NCQA. SFY 2026 CARDINAL CARE PWP METHODOLOGY SFY 2026 Cardinal Care Performance Withhold Program Methodology Page 6 Commonwealth of Virginia SFY 2026 Cardinal Care Performance Withhold Program Methodology_F1_1025 Table 4—PWP HEDIS Measure/Indicator Scoring Criteria for Each Measure/Indicator Score MCO’s rate is below the lower percentile threshold 0.00 MCO’s rate is at or above the lower percentile threshold but below the upper percentile threshold Between 0.00 and 1.00 MCO’s rate is at or above the upper percentile threshold 1.00 For the Follow-Up After ED Visit for Mental Illness—7-Day Follow-Up—Total and 30-Day Follow-Up— Total, and Initiation and Engagement of SUD Treatment—Initiation of SUD Treatment—Total indicators, the lower percentile threshold will be the 50th percentile and the upper percentile threshold will be the 66.67th percentile. For all other HEDIS measures/indicators, the lower percentile threshold will be the 25th percentile and the upper percentile threshold will be the 50th percentile. HEDIS measure/indicator rates that are below the lower percentile threshold will receive a score of zero (i.e., no portion of the quality withhold will be earned for this indicator). Measure/indicator rates that are at or above the upper percentile threshold will receive the maximum score for that measure/indicator (i.e., 1 point). If a measure/indicator rate is at or above the lower percentile threshold but below the upper percentile threshold, the MCO will be eligible to receive a partial score (i.e., a partial point value that falls between 0 and 1). To calculate the partial points at the measure/indicator level, each MCO’s rate will be compared to the percentiles to determine how close the MCO’s rate is to the upper percentile threshold. In future iterations of the PWP, the lower percentile threshold and upper percentile threshold may increase to encourage continued positive performance and quality improvement. The partial score for each measure/indicator will be derived using the following formula: For example, if the lower percentile threshold is 40 percent and the upper percentile threshold is 60 percent, and an MCO has a rate of 55 percent for a measure/indicator, then the partial point value is calculated as follows: Improvement Bonus For the AHRQ PDI and CMS Adult Core Set measures, DMAS will determine an appropriate method of assigning improvement bonus points for future iterations of the PWP, if applicable. For the SFY 2026 PWP, MCOs that failed to meet the upper percentile threshold in CY 2024 (i.e., HEDIS MY 2024 data) for a HEDIS measure/indicator may be eligible to earn an improvement bonus if a measure/indicator rate demonstrates substantial improvement from CY 2024. Substantial improvement will be defined as 20 percent of the difference between the lower and upper percentile SFY 2026 CARDINAL CARE PWP METHODOLOGY SFY 2026 Cardinal Care Performance Withhold Program Methodology Page 7 Commonwealth of Virginia SFY 2026 Cardinal Care Performance Withhold Program Methodology_F1_1025 thresholds. An improvement bonus of 0.25 points will be awarded for each measure/indicator, if the MCO was below the upper percentile threshold in CY 2024 and the following is true: For each MCO, HSAG will assess which measure/indicator rates are eligible for an improvement determination. HSAG will only determine improvement bonus eligibility if a measure/indicator meets the following criteria: • The MCO current year rate demonstrated an improvement from the CY 2024 rate; • The MCO reported the measure/indicator rate in both the current year and CY 2024; • The MCO’s reported measure/indicator rate was below the upper percentile threshold in CY 2024; • The MCO reported the measure/indicator rate using the same reporting methodology in both years (e.g., the reporting methodology did not change from administrative in CY 2024 to hybrid in the current year); and • NCQA did not recommend a break in trending for the measure/indicator due to a change in the technical specifications for the Medicaid product line. If an MCO demonstrates substantial improvement for a measure/indicator rate and meets all of the criteria for improvement bonus determinations, then the MCO will receive an improvement bonus for that measure/indicator. High Performance Bonus For the SFY 2026 PWP, if an MCO demonstrates a strong performance trend over time for a HEDIS measure/indicator, the MCO will be eligible for a high performance bonus. For the Follow-Up After ED Visit for Mental Illness—7-Day Follow-Up—Total and 30-Day Follow-Up—Total, and Initiation and Engagement of SUD Treatment—Initiation of SUD Treatment—Total indicators, the high performance value will be the 75th percentile. For all other HEDIS measures/indicators, the high performance value will be the 66.67th percentile. The high performance bonus will be awarded for measure/indicator rates that exceed the high performance value for both the current year and CY 2024. Each measure/indicator rate that is awarded the high performance bonus will be eligible for a maximum high performance bonus of 0.25 points that will be added to the measure/indicator partial score described above (i.e., 1 point). For the AHRQ PDI and CMS Adult Core Set measures, beginning in SFY 2028, DMAS may determine an appropriate method of assigning high performance bonus points for the PWP. Scoring Model Example Table 5 and Table 6 provide examples of how measure/indicator partial scores will be determined by MCO. All data presented in the tables below (both measure/indicator rates and percentile values) are mock data and do not represent actual data or results. SFY 2026 CARDINAL CARE PWP METHODOLOGY SFY 2026 Cardinal Care Performance Withhold Program Methodology Page 8 Commonwealth of Virginia SFY 2026 Cardinal Care Performance Withhold Program Methodology_F1_1025 Table 5—Measure/Indicator Partial Score Calculations—HEDIS Measures/Indicators (Example Using Mock Data) Measure/Indicator Current Year Rate Lower Percentile Threshold Upper Percentile Threshold Measure/ Indicator Partial Score Child and Adolescent Well-Care Visits Total 55.55% 44.28% 54.26% 1.00 Childhood Immunization Status Combination 3 73.82% 65.45% 70.68% 1.00 Comprehensive Diabetes Care Composite Blood Pressure Control for Patients With Diabetes—Total 53.00% 50.23% 54.55% 0.64 Eye Exam for Patients With Diabetes—Total 42.68% 41.77% 52.00% 0.09 Glycemic Status Assessment for Patients With Diabetes—Glycemic Status <8.0%—Total 54.74% 44.11% 51.22% 1.00 Glycemic Status Assessment for Patients With Diabetes—Glycemic Status >9.0%—Total* 50.70% 45.55% 38.66% 0.00 Follow-Up After ED Visit for Substance Use 7-Day Follow-Up—Total 6.94% 6.25% 9.73% 0.20 30-Day Follow-Up—Total 11.04% 9.89% 15.25% 0.21 Follow-Up After ED Visit for Mental Illness 7-Day Follow-Up—Total 46.22% 29.21% 35.49% 1.00 30-Day Follow-Up—Total 58.92% 43.17% 51.45% 1.00 Initiation and Engagement of SUD Treatment Initiation of SUD Treatment—Total 42.26% 39.25% 41.99% 1.00 Engagement of SUD Treatment— Total 11.16% 9.53% 11.01% 1.00 Prenatal and Postpartum Care Timeliness of Prenatal Care—Total 78.01% 78.10% 83.76% 0.00 Postpartum Care—Total 64.70% 59.38% 65.69% 0.84 *For this measure/indicator, a lower rate indicates better performance. Please note that the numbers in the table have been rounded for display purposes. Calculations will be based off unrounded data. SFY 2026 CARDINAL CARE PWP METHODOLOGY SFY 2026 Cardinal Care Performance Withhold Program Methodology Page 9 Commonwealth of Virginia SFY 2026 Cardinal Care Performance Withhold Program Methodology_F1_1025 Table 6—Measure/Indicator Partial Score Calculations—AHRQ PDI and CMS Adult Core Set Measures (Example Using Mock Data) Measure Audit Designation* Met Reporting Requirements Measure Partial Score Asthma Admission Rate (per 100,000 MM) Total R Yes 1.00 COPD or Asthma in Older Adults Admission Rate (per 100,000 MM) Total R Yes 1.00 Heart Failure Admission Rate (per 100,000 MM) Total NA No 0.00 *Audit designations include: Reportable (R); Do Not Report (DNR); Not Applicable (NA); No Benefit (NR). The measure/indicator partial scores for the HEDIS measures/indicators are calculated by first determining the applicable percentile level for the measure/indicator rate. For example, the Follow-Up After ED Visit for Mental Illness—7-Day Follow-Up—Total indicator received a measure/indicator partial score of one point because the rate (46.22 percent) is above the upper percentile threshold (35.49 percent). For the AHRQ PDI and CMS Adult Core Set measures, the Asthma Admission Rate—Total measure receives a measure partial score of 1.00 because the audit designation was “Reportable (R). Table 7 provides an example of how the improvement bonus scores will be determined by MCO based on performance for the current year and CY 2024 for the HEDIS measures/indicators. Improvement bonus determinations for the AHRQ PDI and CMS Adult Core Set measures will be evaluated for future iterations of the PWP. Table 7—Measure/Indicator Improvement Bonus Score Calculations—HEDIS Measures/Indicators (Example Using Mock Data) Measure/Indicator CY 2024 Rate Current Year Rate Rate Difference Substantial Improvement Value Below Upper Percentile Threshold in Prior Year Met Substantial Improvement Improvement Bonus† Child and Adolescent Well-Care Visits Total 50.85% 55.55% 4.70% 2.00% Y Y 0.25 Childhood Immunization Status Combination 3 71.29% 73.82% 2.53% 1.05% N Y 0.00 SFY 2026 CARDINAL CARE PWP METHODOLOGY SFY 2026 Cardinal Care Performance Withhold Program Methodology Page 10 Commonwealth of Virginia SFY 2026 Cardinal Care Performance Withhold Program Methodology_F1_1025 Measure/Indicator CY 2024 Rate Current Year Rate Rate Difference Substantial Improvement Value Below Upper Percentile Threshold in Prior Year Met Substantial Improvement Improvement Bonus† Comprehensive Diabetes Care Composite Blood Pressure Control for Patients With Diabetes—Total 53.25% 53.00% -0.25% 0.86% Y N 0.00 Eye Exam for Patients With Diabetes—Total 44.27% 42.68% -1.59% 2.05% Y N 0.00 Glycemic Status Assessment for Patients With Diabetes—Glycemic Status <8.0%—Total 57.41% 54.74% -2.67% 1.42% N N 0.00 Glycemic Status Assessment for Patients With Diabetes—Glycemic Status >9.0%—Total* 52.26% 50.70% -1.56% -1.38% Y Y 0.25 Follow-Up After ED Visit for Substance Use 7-Day Follow-Up— Total 5.66% 6.94% 1.28% 0.70% Y Y 0.25 30-Day Follow-Up— Total 11.42% 11.04% -0.38% 1.07% Y N 0.00 Follow-Up After ED Visit for Mental Illness 7-Day Follow-Up— Total 45.12% 46.22% 1.10% 1.26% N N 0.00 30-Day Follow-Up— Total 59.67% 58.92% -0.75% 1.66% N N 0.00 Initiation and Engagement of SUD Treatment Initiation of SUD Treatment—Total 41.68% 42.26% 0.58% 0.55% N Y 0.00 Engagement of SUD Treatment—Total 11.11% 11.16% 0.05% 0.30% Y N 0.00 Prenatal and Postpartum Care Timeliness of Prenatal Care—Total 77.62% 78.01% 0.39% 1.13% Y N 0.00 SFY 2026 CARDINAL CARE PWP METHODOLOGY SFY 2026 Cardinal Care Performance Withhold Program Methodology Page 11 Commonwealth of Virginia SFY 2026 Cardinal Care Performance Withhold Program Methodology_F1_1025 Measure/Indicator CY 2024 Rate Current Year Rate Rate Difference Substantial Improvement Value Below Upper Percentile Threshold in Prior Year Met Substantial Improvement Improvement Bonus† Postpartum Care— Total 60.58% 64.70% 4.12% 1.26% Y Y 0.25 †A measure/indicator is eligible for an improvement bonus if the measure/indicator rate was below the upper percentile in CY 2024 and the measure/indicator rate demonstrated substantial improvement from CY 2024. *For this measure/indicator, a lower rate indicates better performance. Table 8 provides an example of how the high performance bonus scores will be determined, by MCO, based on performance for the current year and CY 2024 for the HEDIS measures/indicators. Once the high performance bonus scores are determined, the measure/indicator partial score, the improvement bonus score, and high performance bonus score (i.e., 0.00 or 0.25) will be summed to obtain the final measure/indicator score. High performance bonus determinations for the AHRQ PDI and CMS Adult Core Set measures will be evaluated for future iterations of the PWP. Table 8—High Performance Bonus Score Calculations—HEDIS Measures/Indicators (Example Using Mock Data) Measure/Indicator CY 2024 Rate CY 2024 High Performance Value Current Year Rate Current Year High Performance Value High Performance Bonus Prior Year Current Year Points Earned Child and Adolescent Well-Care Visits Total 50.85% 59.49% 55.55% 60.34% N N 0.00 Childhood Immunization Status Combination 3 71.29% 73.72% 73.82% 72.75% N Y 0.00 Comprehensive Diabetes Care Composite Blood Pressure Control for Patients With Diabetes—Total 53.25% 56.12% 53.00% 57.89% N N 0.00 Eye Exam for Patients With Diabetes—Total 44.27% 57.16% 42.68% 58.02% N N 0.00 Glycemic Status Assessment for Patients With Diabetes—Glycemic Status <8.0%—Total 57.41% 53.48% 54.74% 54.51% Y Y 0.25 Glycemic Status Assessment for Patients With Diabetes—Glycemic Status >9.0%—Total* 52.26% 33.23% 50.70% 34.15% N N 0.00 SFY 2026 CARDINAL CARE PWP METHODOLOGY SFY 2026 Cardinal Care Performance Withhold Program Methodology Page 12 Commonwealth of Virginia SFY 2026 Cardinal Care Performance Withhold Program Methodology_F1_1025 Measure/Indicator CY 2024 Rate CY 2024 High Performance Value Current Year Rate Current Year High Performance Value High Performance Bonus Prior Year Current Year Points Earned Follow-Up After ED Visit for Substance Use 7-Day Follow-Up—Total 5.66% 10.85% 6.94% 11.01% N N 0.00 30-Day Follow-Up—Total 11.42% 15.30% 11.04% 15.75% N N 0.00 Follow-Up After ED Visit for Mental Illness 7-Day Follow-Up—Total 45.12% 44.56% 46.22% 45.77% Y Y 0.25 30-Day Follow-Up—Total 59.67% 54.66% 58.92% 55.79% Y Y 0.25 Initiation and Engagement of SUD Treatment Initiation of SUD Treatment—Total 41.68% 47.00% 42.26% 48.04% N N 0.00 Engagement of SUD Treatment—Total 11.11% 12.16% 11.16% 12.13% N N 0.00 Prenatal and Postpartum Care Timeliness of Prenatal Care—Total 77.62% 85.59% 78.01% 86.37% N N 0.00 Postpartum Care—Total 60.58% 67.82% 64.70% 68.36% N N 0.00 *For this measure/indicator, a lower rate indicates better performance. Table 9 shows the domain level score calculations for each MCO by determining the average of the measure/indicator level scores for each measure/indicator. Table 9—Domain Level Score Calculations (Example Using Mock Data) Measure/Indicator Measure/ Indicator Level Score Improvement Bonus High Performance Bonus Final Measure/ Indicator Score Domain Level Score Asthma Admission Rate (Per 100,000 MM)* Total 1.00 NE NE 1.00 1.00 Child and Adolescent Well-Care Visits Total 1.00 0.25 0.00 1.25 1.25 Childhood Immunization Status Combination 3 1.00 0.00 0.00 1.00 1.00 COPD or Asthma in Older Adults Admission Rate (per 100,000 MM)* Total 1.00 NE NE 1.00 1.00 SFY 2026 CARDINAL CARE PWP METHODOLOGY SFY 2026 Cardinal Care Performance Withhold Program Methodology Page 13 Commonwealth of Virginia SFY 2026 Cardinal Care Performance Withhold Program Methodology_F1_1025 Measure/Indicator Measure/ Indicator Level Score Improvement Bonus High Performance Bonus Final Measure/ Indicator Score Domain Level Score Comprehensive Diabetes Care Composite Blood Pressure Control for Patients with Diabetes— Total 0.64 0.00 0.00 0.64 0.56 Eye Exam for Patients with Diabetes—Total 0.09 0.00 0.00 0.09 Glycemic Status Assessment for Patients With Diabetes—Glycemic Status <8.0%—Total 1.00 0.00 0.25 1.25 Glycemic Status Assessment for Patients With Diabetes—Glycemic Status >9.0%—Total* 0.00 0.25 0.00 0.25 Follow-Up After ED Visit for Substance Use 7-Day Follow-Up—Total 0.20 0.25 0.00 0.45 0.33 30-Day Follow-Up—Total 0.21 0.00 0.00 0.21 Follow-Up After ED Visit for Mental Illness 7-Day Follow-Up—Total 1.00 0.00 0.25 1.25 1.25 30-Day Follow-Up—Total 1.00 0.00 0.25 1.25 Heart Failure Admission Rate (per 100,000 MM)* Total 0.00 NE NE 0.00 0.00 Initiation and Engagement of SUD Treatment Initiation of SUD Treatment—Total 1.00 0.00 0.00 1.00 1.00 Engagement of SUD Treatment—Total 1.00 0.00 0.00 1.00 Prenatal and Postpartum Care Timeliness of Prenatal Care—Total 0.00 0.00 0.00 0.00 0.55 Postpartum Care—Total 0.84 0.25 0.00 1.09 Please note that the numbers in the table have been rounded for display purposes. Calculations will be based off unrounded data. NE indicates the measure/indicator is not eligible for an Improvement Bonus or High Performance Bonus. *For this measure/indicator, a lower rate indicates better performance. SFY 2026 CARDINAL CARE PWP METHODOLOGY SFY 2026 Cardinal Care Performance Withhold Program Methodology Page 14 Commonwealth of Virginia SFY 2026 Cardinal Care Performance Withhold Program Methodology_F1_1025 As shown in Table 9, the Follow-Up After ED Visit for Substance Use domain level score (0.33) was obtained by averaging the measure/indicator level scores for 7-Day Follow-Up—Total and 30-Day Follow-Up—Total (0.45 and 0.21 respectively). Table 10 provides an example of how the percentage of the quality withhold is derived (i.e., overall withhold earned) based on the 10 domain level scores calculated above. The percentage of the quality withhold that the MCO is eligible to earn back is calculated by multiplying the domain level score with the applicable domain weight and then summing the domain withhold earned values together. An MCO is not able to earn back more than 100 percent of its total withhold amount. If an overall withhold amount is greater than 100 percent (due to bonus points), the overall withhold earned will be reduced to 100 percent. Table 10—Percentage Withhold Earned (Example Using Mock Data) Domain Domain Level Score Domain Weight Domain Withhold Earned Overall Withhold Earned Asthma Admission Rate (per 100,000 MM) 1.00 10.00% 10.00% 79.33% Child and Adolescent Well-Care Visits 1.25 10.00% 12.50% Childhood Immunization Status 1.00 10.00% 10.00% COPD or Asthma in Older Adults Admission Rate (per 100,000 MM) 1.00 10.00% 10.00% Comprehensive Diabetes Care Composite 0.56 10.00% 5.58% Follow-Up After ED Visit for Substance Use 0.33 10.00% 3.30% Follow-Up After ED Visit for Mental Illness 1.25 10.00% 12.50% Heart Failure Admission Rate (per 100,000 MM) 0.00 10.00% 0.00% Initiation and Engagement of SUD 1.00 10.00% 10.00% Prenatal and Postpartum Care 0.55 10.00% 5.45% Please note that the numbers in the table have been rounded for display purposes. Calculations will be based off unrounded data. Quality Withhold Funds Model For SFY 2026, the quality withhold percentage is 1 percent of the total MCO capitation payments for the year. An MCO is eligible to earn the entire quality withhold by having 100 percent for the overall withhold (i.e., the MCO would not lose any quality withhold funds). SFY 2026 CARDINAL CARE PWP METHODOLOGY SFY 2026 Cardinal Care Performance Withhold Program Methodology Page 15 Commonwealth of Virginia SFY 2026 Cardinal Care Performance Withhold Program Methodology_F1_1025 Table 11—PWP Funds Allocation (Example Using Mock Data) MCO Name Total Capitation Payment Maximum At- Risk Amount (1% Withhold) Percentage Withhold Earned Final Withhold Earned Back Amount MCO $735,790,000.00 $7,357,900.00 79.33% $5,836,654.18 Please note that the numbers in the table have been rounded for display purposes. Calculations will be based off unrounded data. As shown in Table 11, the one percent at risk amount for the example MCO is $7,357,900.00. The MCO earned 79.33 percent of the quality withhold through the review of the HEDIS, AHRQ PDI, and CMS Adult Core Set measure/indicator rates, thus the MCO is eligible to receive $5,836,654.18 of the quality withhold according to the following equation: 𝐹𝐹𝑃𝑃𝑜𝑜𝑃𝑃𝑃𝑃 𝑊𝑊𝑃𝑃𝑃𝑃ℎℎ𝑜𝑜𝑃𝑃𝑜𝑜 𝐸𝐸𝑃𝑃𝑃𝑃𝑜𝑜𝑉𝑉𝑜𝑜 𝐵𝐵𝑃𝑃𝑃𝑃𝐵𝐵 𝐴𝐴𝐴𝐴𝑜𝑜𝑉𝑉𝑜𝑜𝑃𝑃 = (𝑀𝑀𝑃𝑃𝑀𝑀𝑃𝑃𝐴𝐴𝑉𝑉𝐴𝐴 𝐴𝐴𝑃𝑃 𝑅𝑅𝑃𝑃𝑟𝑟𝐵𝐵 𝐴𝐴𝐴𝐴𝑜𝑜𝑉𝑉𝑜𝑜𝑃𝑃 × 𝑃𝑃𝑉𝑉𝑃𝑃𝑃𝑃𝑉𝑉𝑜𝑜𝑃𝑃𝑃𝑃𝑃𝑃𝑉𝑉 𝑊𝑊𝑃𝑃𝑃𝑃ℎℎ𝑜𝑜𝑃𝑃𝑜𝑜 𝐸𝐸𝑃𝑃𝑃𝑃𝑜𝑜𝑉𝑉𝑜𝑜)