Supports and rewards practices which meet performance expectations.
| Alabama | Under the state’s new regional pilot to support primary care providers to function as medical homes through Patient Care Networks, Medicaid will pay the networks $3PMPM for members of the non-ABD population and $5 PMPM for members of the ABD population. Additionally, Medicaid will pay an additional $1.60-$2.10 PMPM care management payment to participating network providers on top of the base $1.00 Patient 1st care management PMPM. Medicaid varies the additional network provider payment based on the patient panel’s average acuity level. |
| Alaska | No known activity at this time. |
| Arizona | No known activity at this time. |
| Arkansas | Arkansas’s “Transforming Arkansas Medicaid” initiative includes an effort to move Arkansas’s Medicaid payment system from a traditional fee-for-service model to one that pays providers for episodes of care (acute, sub-acute or chronic) in bundled payments. In their proposal, the state lists Arkansas BlueCross and BlueShield as potential partner in this new payment system. |
| California | No known activity at this time. |
| Colorado |
Medical Homes for Children Program: Certified providers receive pay-for-performance enhanced reimbursement for EPSDT/well-child visits.
Accountable Care Collaborative (ACC) Program:
Under the Accountable Care Collaborative (ACC) Program, a total of $20 per-member/per-month (PMPM) is divided among three entities
Once a RCCO shows cost neutrality, $1 PMPM is withheld from both the PCMP and RCCO, creating a shared quarterly incentive payment pool. The $1 PMPM can be recouped by each entity by meeting specific performance goals. * Pediatric PCMPs cannot receive enhanced payments from both the Medical Homes for Children and the ACC programs. They are only eligible to receive the Medical Home for Children Program performance payments for their patients.
HealthTeamWorks Multi-payer Pilot:
Participating HealthTeamWorks pilot sites receive enhanced care management and performance-based payments on top of fee for service reimbursement. Multi-payer pilot sites may also participate in the ACC, but individual patients may only be attributed to one program at any given time.
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| Connecticut |
Connecticut Medicaid is using a hybrid payment system under the new HUSKY Health program that is dependent upon NCQA recognition and Glide Path status. In total, the new reimbursement model will allow practices to earn up to 125 percent of the estimated medical home costs.
NCQA Level 2 or Level 3 practices:
Incentive Payments:Practices in the top tenth percentile for performance will receive 100 percent of the possible incentive payment, and fractions of the incentive payment begin phasing in at the 25th percentile.
Improvement Payments:Practices in the top tenth percentile for improvement will receive 100 percent of the possible improvement payment. Practices with a 5 percent improvement will receive half of the possible improvement payment, and practices with a 10 percent improvement will receive three-quarters.
Connecticut Medicaid plans to pursue alternative payment methods and intends to develop a prospective per member per month (PMPM) methodology for qualified providers by 2014.
Glide Path practices:
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| Delaware | No known activity at this time. |
| District of Columbia | No known activity at this time. |
| Florida | No known activity at this time. |
| Georgia | No known activity at this time. |
| Hawaii | No known activity at this time. |
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An Idaho Medical Home Collaborative workgroup composed of payers and providers working together to identify sustainable common payment methodology.
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Illinois Health Connect pays primary care providers enhanced fee-for-service rates in addition to the following ongoing care management fees:
Illinois Health Connect primary care providers are also eligible for performance-based payments. In previous years, about $3.3 million has been paid for achieving clinical targets. For 2011, bonuses will depend on performance in the following six areas:
Information on specific performance targets is available online.
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| Indiana | No known activity at this time. |
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For the IowaCare program, participating health centers will receive PMPM payments for care coordination ranging from $1.50-$3.50, depending on medical home level. Performance-based PMPM payments ranging from $1.00-$1.50 will be made as well.
Iowa also plans to begin paying primary care providers for remote consultations with hospital-based specialist in order to support transition planning for hospitalized patients. This strategy is intended to support care coordination in remote areas of the state where face-to-face consultations between hospitals and medical home practices are impractical.
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| Kansas | No known activity at this time. |
| Kentucky | No known activity at this time. |
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Under Bayou Health, the Louisiana Department of Health and Hospitals (DHH) is simultaneously implementing two separate models:
Both RFPs allow networks to develop performance-based physician incentive plans.
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For the duration of the Maine Patient-Centered Medical Home (PCMH) Pilot, participating practices will receive per member per month (PMPM) payments of $7.00 for each eligible MaineCare (Medicaid) beneficiary. Medicare fee-for-service will be paying $6.95 PMPM to the practices and $2.95 PMPM to the Community Care Teams (CCTs).
In addition to MaineCare and Medicare fee-for-service, three commercial payers – Anthem Blue Cross Blue Shield, Aetna, and Harvard Pilgrim – are also voluntarily participating in the Pilot. The amount that commercial insurers pay to practices is not publicly available.
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Aetna, CareFirst BlueCross BlueShield, CIGNA, United Healthcare, and Coventry are required to make payments to participating practices under SB 855/HB 929. Medicaid has budgeted $1.5 million for fiscal year 2012 to provided fixed transformation payments. Further information on the methodology that these payers will use to attribute patients is available in the practice participation agreement.
Participating providers are eligible for ongoing per member per month payments (PMPM) referred to in Maryland as “fixed transformation payments”. Practices may also be eligible for “incentive payments” as described below.
Fixed transformation payments are calculated as specified below. In general, smaller practices receive higher PMPM payments than larger practices all else being equal. Likewise, practices with higher recognition levels receive greater PMPMs. Federally qualified health centers (FQHCs) are not eligible for fixed transformation payments. The exact amounts of the fixed transformation payments are adjusted annually on the basis of the Medicare Economic Index.
Commercial Population
Practice sites with fewer than 10,000 patients:
Level 1+: $4.68 PMPM
Level 2+: $5.34 PMPM
Level 3+: $6.01 PMPM
Practice sites with 10,000-20,000 patients:
Level 1+: $3.90 PMPM
Level 2+: $4.45 PMPM
Level 3+: $5.01 PMPM
Practice sites with more than 20,000 patients:
Level 1+: $3.51 PMPM
Level 2+: $4.01 PMPM
Level 3+: $4.51 PMPM
Medicaid Population
All practice sizes:
Level 1+: $4.54 PMPM
Level 2+: $5.19 PMPM
Level 3+: $5.84 PMPM
Medicare Advantage Population
All practice sizes:
Level 1+: $8.66 PMPM
Level 2+: $9.62 PMPM
Level 3+: $11.54 PMPM
All participating practices—including FQHCs—are eligible for incentive payments if they meet performance criteria. The performance criteria include measures around evidence-based practices and utilization reduction such as:
Practices that meet the performance criteria will then be entitled to payments of 30 percent to 50 percent of any savings generated by the practice. FQHCs will be able to share in 65 percent of savings for patients with Medicaid coverage.
Savings will be calculated separately for the commercially insured, Medicaid, and Medicare Advantage populations. The calculations will entail comparing expected costs for a given practice’s population (as derived from baseline data) with actual costs for the practice population. Expected costs will be adjusted to include medical inflation. It should be noted that fixed transformation payments will be included in determining actual costs. Therefore, practices must generate savings beyond the amount of the fixed transformation payments in order to be eligible for incentive payments. (FQHCs are eligible for “first dollar” shared savings, as they are not receiving fixed transformation payments.) Provision is made for the Maryland Health Care Commission (MHCC) to adjust the incentive payment algorithm in recognition of changes in practice case mix or for outliers.
Full details on the payment methodology are available online in the practice participation agreement.
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The following payers and purchasers are making enhanced payments through the Massachusetts Patient-Centered Medical Home Initiative (PCMHI):
Payers have committed to making several types of payments to support medical homes:
It should be noted that Medicaid managed care plans are required to make PCMHI payments.
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Starting January 2012, participating practices and providers in the Michigan Primary Care Transformation (MiPCT) Project will receive three per-member per-month (PMPM) payments for each attributed patient:
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Medicaid received state plan amendment approval from the Centers for Medicare & Medicaid Services (CMS) in July 2010 to begin making health care homes payments. As per Minnesota law, state-regulated payers are required to pay for health care home services in manners that are consistent with the Medicaid fee-for-service methodology.
The following payers and purchasers are making enhanced payments:
Payments vary by the number of chronic conditions a patient has. A provider caring for a Medicare patient with one major chronic conditions receives a payment of $10.14 per member per month (PMPM); the rate increases to $45.00 PMPM for a patient with ten or more chronic conditions. The monthly PMPM payment is increased by 15% if a patient’s (or patient caregiver’s) primary language is not English or if the patient (or patient caregiver) has a severe and persistent mental illness. If both of these complexity factors are present, the PMPM is increased by 30%.
It should be noted that Medicaid managed care plans are required to make enhanced payments.
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| Mississippi | No known activity at this time. |
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ACA Section 2703 Health Home State Plan Amendment – Community Mental Health Centers: Health home teams in community mental health centers receive a combined $78.74 per-member per-month payment to fund the services of a nurse care manager, a primary care physician consultant, a health home director, and health home administrative support. MOHealthNet will review the payment methodology after 18 months (including an exploration of whether to tier the payment) and will adjust annually according to the consumer price index (CPI).
Payments for health home enrollees participating in a managed care plan will be made directly from Medicaid to the health home provider.
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| Montana | No known activity at this time. |
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Nebraska has developed a unique payment structure. Upon signing an agreement with the Nebraska Department of Health and Human Services (DHHS), practices are paid $2.00 per member per month (PMPM). After achieving Tier 1 recognition, the PMPM increases to $4.00. The practice then has the option of continuing to transform to meet the advanced standards (Tier 2). For achieving Tier 2 recognition, practices receive 105% of standard rates for select evaluation and management and preventive codes.
Authority for Nebraska’s payment methodology came in January 2011 with the approval of a 1932(a) state plan amendment.
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| Nevada | No known activity at this time. |
| New Hampshire | No known activity at this time. |
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Each of the four New Jersey Medicaid managed care organizations (MCOs) is administering its own medical home pilot, and information is not available on the specific payment methodologies that each MCO will use to pay medical home-recognized practices. The MCO contract states that each MCO must submit its proposed reimbursement methodology to the state for approval. It also requires the methodologies to “support care coordination and reward quality and improved patient outcomes.”
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The participating SALUD! Managed Care Organizations (MCOs) are currently funding Medicaid PCMH models and payments to practices through a withhold fund established from capitated payments to the MCOs.
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Adirondack Medical Home Demonstration: Participating payers made incentive payments totaling $84 per-member per-year to support practice transformation and new care coordination services. Payment frequency was left to each payer (i.e., some paid $7 monthly, some $21 quarterly). Providers must reach NCQA PCMH Level 2 or 3 recognition within 12-18 months to continue receiving these enhanced payments.
Providers receiving Adirondack Demonstration payments are not eligible for additional payments under the Statewide Patient-Centered Medical Home Program.
Statewide Patient-centered Medical Home Program: NCQA-recognized hospital outpatient clinics and office-based practitioners are eligible to receive enhanced service rates for certain evaluation and management (E&M) and preventative medicine codes for participating enrollees. Payments vary by NCQA level.
Hospital outpatient clinics (including FQHCs):
Office-based practitioners:
Medicaid will discontinue payments to Level 1 NCQA PCMH providers in December 2012.
Managed care plans pay a per-member per-month (PMPM) incentive payment for each participating enrollee. This payment is also tiered by NCQA recognition:
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Currently, Community Care of North Carolina (CCNC) providers and networks both receive per-member per-month (PMPM) payments for each patient under their care. For CCNC providers, this PMPM payment is in addition to fee-for-service reimbursement.
CCNC providers receive:
CCNC Networks receive:
However, to support the central office, networks return $3.17 and $0.54 monthly for each ABD and non-ABD enrollee.
Prior to statewide expansion and ABD participation, CCNC networks and providers both received $2.50 PMPM for each enrollee.
Carolina Access providers not participating in the Community Care of North Carolina program receive $1.00 PMPM.
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| North Dakota | No known activity at this time. |
| Ohio | Substitute House Bill 198 (128th General Assembly) requires the patient-centered medical home education advisory group to reimburse up to 75 percent of a practice’s health information technology investments for participating primary care practices (including training and technical support). Ohio is using meaningful use incentives in the HITECH Act to meet this requirement. |
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SoonerCare Choice utilizes multiple payments to incentivize practice transformation. These payments include:
*Providers can use additional codes to bill for enhanced reimbursement when providing care outside of normal business hours.
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Chapter 595 of the 2009 Oregon Laws authorized Medicaid reimbursement for Patient-Centered Primary Care Home (PCPCH) services. The law also authorized reimbursement for interpretive services provided to medical assistance beneficiaries if such services qualified for federal financial participation.
A learning collaborative created by the law was charged with coordinating efforts to develop and test methods to align financial incentives to support PCPCHs. Chapter 595 also provided Parker antitrust immunity to public payers, private health carriers, third party purchasers and providers, allowing collaboration to identify appropriate reimbursement methods to align incentives in support of patient centered primary care homes.
Chapter 590 of the Acts of 2009 required that, if feasible, the PCPCH reimbursement system include:
Chapter 590 also granted the Department of Human Services authority to develop additional incentive payments to transform the current primary care delivery system and improve the population’s health outcomes, such as:
Oregon plans to reimburse providers for currently care coordination services that were previously non‐reimbursable. The Oregon Health Policy Board has directed the Oregon Health Authority to pursue innovative payment methodologies. Such innovative payment methodologies must:
If an MCO or carrier does not pursue an innovative payment arrangement, a specific additional payment is made to practices meeting PCPCH criteria. This payment corresponds to the PCPCH Tier for which a practice qualifies (Tier 3 > Tier 2 > Tier 1). When developing the payment rate, the MCO and/or carrier must consider the costs practices incur for meeting the PCPCH criteria, including, but not limited to:
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Under Phase I, different rollouts of the Chronic Care Initiative (CCI) in Pennsylvania tested different payment models, including lump sum payments to practices to cover start-up infrastructure costs, per member per month payments, and shared savings. Enhanced payments were stratified by practice recognition, with higher level practices receiving greater enhanced payment than lower level practices. Since 2009, the state’s contracts with Medicaid managed care organizations (MCOs) have required MCOs to participate in the CCI. Medicaid fee-for-service – which is a payer only in the Northeast region – did not provide enhanced payments to practices under Phase I.
Under Phase II, practices will receive per member per month (PMPM) payments from participating payers, including Medicare, Medicaid MCOs, and Medicaid fee-for-service. The amounts of these PMPM payments will vary by initiative year and patient age. Payers are making two PMPM payments to practices.
Year 1: $0.60
Year 2: $0.51 Year 3: $0.43
Year 1: $1.50
Year 2: $1.28 Year 3: $1.08
Year 1: $5.00
Year 2: $4.25 Year 3: $3.61
Year 1: $7.00
Year 2: $5.95 Year 3: $5.06 Practices will be eligible for shared savings payments that will take into consideration practice performance on key quality and cost metrics. As the PMPM amounts decrease from year 1 to year 3, practices will be eligible for greater shares of any savings.
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Chronic Care Sustainability Initiative (CSI-RI): Under CSI-RI, nearly 100% of payers in Rhode Island are using a common approach to reimburse participating medical homes for providing enhanced services. Prior to Medicare’s participation, the payers shared in the expenses of providing practice-based nurse care managers. They also paid flat $3.00 per member per month (PMPM) fees to participating practices for each attributed patient.
Under the new payment methodology, the participating payers will pay the five pilot practices $5.50 PMPM in the first year, and either $5.00, $5.50, or $6.00 in years two and three depending on practice performance on key quality and cost metrics. The eight expansion practices will receive $3.00 PMPM plus $1.16 PMPM if the practices hire a nurse care manager. If the practices choose to contract with a local hospital to provide nurse care management services, the hospital will receive the $1.16 PMPM stream.
Connect Care Choice (CCC): Practices receive monthly care coordination fees intended to account for the time needed to care for complex patients. Practices that care for moderate to high-risk CCC members and have a nurse care manager integrated into their practice receive PMPM payments of $35-40 PMPM.
CEDARR Family Centers: CEDARR (Comprehensive Evaluation Diagnosis Assessment Referral Re-evaluation) Family Centers receive three distinct bundled rates for services that they perform: initial family intake and needs assessments ($366), family care plan development ($347), and family care plan reviews ($397). Additionally, primary care providers are eligible for enhanced reimbursement for collaborating on care planning with the CEDARR Family Centers.
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| South Carolina | No known activity at this time. |
| South Dakota | No known activity at this time. |
| Tennessee | No known activity at this time. |
| Texas | No known activity at this time. |
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Utah’s Children’s Health Insurance Program Reauthorization (CHIPRA) proposal anticipated payments of $40,000 for each participating pediatrician in primary care, and payments of $40,000 for each pediatric subspecialty practice. Over the course of the project, increasing shares of compensation will depend on practice performance. A project budget is included on page 8 of the proposal.
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Practices receive enhanced per-member per-month (PMPM) payment ranging from $1.20-$2.39 that varies by NCQA PCMH recognition score, in addition to fee-for-service reimbursement.
All payers share responsibility in funding at total of $350,000 for each Community Health Team (CHT). CHTs consist of five FTEs for every 20,000 Vermonters in the CHT’s service area.
Prior to Medicare’s direct participation under the Medicare MAPCP demonstration, Vermont subsidized Medicare’s share of payments.
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| Virginia | No known activity at this time. |
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Payer participation in Washington State’s Patient Centered Medical Home (PCMH) Multipayer Reimbursement Pilot is voluntary. The following payers have joined the program on behalf of their commercial, Medicaid managed care, Medicare Advantage, and Basic health lines of business:
For the duration of the Pilot, participating practices will receive per member per month (PMPM) payments and will be eligible for shared savings payment if they reduce avoidable acute care utilization. The amount of the PMPM payment is set at $2.50 initially; it will decrease to $2.00 PMPM after the first nine months. If practices do not achieve savings greater than or equal to the total amount of PMPM payments, they may have to pay back up to half of the PMPM payments. This will be accomplished by reducing the amount of future PMPM payments. Further information on the payment model is available here.
Under the Patient Centered Medical Home (PCMH) Collaborative, participating practices have received stipends of $6,400 per practice to attend eight days of learning sessions.
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Providers and payers participating in the Medical Home Performance Incentive Pilot agreed to share 5 percent of net savings (2.5 percent to providers, 2.5 percent to payers.) Providers also received compensation for lost revenue during learning sessions and NCQA PCMH application costs.
Payer and provider participation in the Medical Home Performance Incentive Pilot is voluntary. The following payers are participating:
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| Wisconsin |
Medicaid Managed Care High Risk Pregnancy Medical Home Pilot: Beginning July 1, 2011, participating providers receive an extra $1,000 for every birth to a member participating in the pilot. This payment doubles to $2,000 if the birth is designated as a good outcome. Alternatively, the managed care plan would be assessed a $2,000 penalty for each birth with poor outcomes or when the mother did not receive satisfactory care. For the purposes of this pilot, a poor birth outcome was defined as any one of the following:
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| Wyoming | No known activity at this time. |
