Aligning Reimbursement & Purchasing

Supports and rewards practices which meet performance expectations.

Alabama Patient Care Networks of Alabama (PCNA) and ACA Section 2703 Health Homes: Alabama began a staggered launch of four PCNAs beginning in August 2011, offering up to $50,000 in reimbursement for start-up costs and $3.00 PMPM for enrollees and $5.00 for enrollees who are aged, blind or disabled (ABD).Following the implementation of the state’s health homes program in July 2012, the PCNA payment methodology moved to align with the health homes program. Separate per-member per-month payments made to the participating providers and Patient Care Networks of Alabama on behalf of health home-eligible Medicaid enrollees.

  • Health home providers receive $8.50 per PMPM: $8.00 through the health homes program in addition to an existing $0.50 PMPM to provide care management services under the state’s 1915(b) wavier.
  • PCNAs receive $9.50 PMPM for each health home patient.
Alaska The Alaska Patient-Centered Medical Home Initiative (AK-PCMH-I) pilot sites will receive a one-time grant of up to $75,000 to support practice transformation efforts over the 18-month project budget period. Grants are supported in part by a capital grantfrom the Alaska State Legislature in addition to funds from the Alaska Department of Health and Social Services and Alaska Mental Health Trust Authority.
Arizona No known activity at this time.
Arkansas CMS’s Comprehensive Primary Care Initiative (CPCi): This four-year multi-payer initiative, launched in October 2012, includes five payers in the Arkansas market: Medicare, Arkansas Medicaid, Arkansas Blue Cross and Blue Shield, Humana, and Qual Choice of Arkansas.Medicare pays selected practices a per-beneficiary per-month (PBPM) risk-adjusted care management fee which ranges from $8 to $40. CMS has indicated that it expects care management fees to average $20 PBPM during the first two years of the initiative. In Years 3 and 4, care management fees will average $15 PBPM. Medicare will also introduce a shared savings component beginning in Year 2, calculated at the market level.The CPCi solicitation for payers indicates that participating payers (non-Medicare) are expected to follow a similar framework, paying per-member per-month (PMPM) care management fees to participating practices on top of fee-for-service and incorporating a shared savings component. Payment amounts will be negotiated individually with participating practices to comply with anti-trust laws.
California No known activity at this time.
Colorado Accountable Care Collaborative (ACC) ProgramUnder the Accountable Care Collaborative (ACC) Program, a total of $20 per-member/per-month (PMPM) is divided among three entities

  • Primary Care Medical Provider (PCMP): $4 PMPM*
  • Regional Care Collaborative Organization (RCCO): $13 PMPM
  • Statewide Data and Analytics Contractor (SDAC): $3 PMPM

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 Key Performance Indicators: reduced emergency room utilization; reduced hospital readmissions; reduced utilization of medical imaging. A fourth measure, well-child visits, was added in July 2013.

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.

Comprehensive Primary Care Initiative (CPCi): This four-year multi-payer initiative, launched in November 2012, includes ten payers in the Colorado market: Medicare, Anthem Blue Cross Blue Shield of Colorado, Cigna, Colorado Access, Colorado Choice Health Plans, Colorado Medicaid, Humana, Rocky Mountain Health Plans, Teamsters Multi-Employer Taft Hartley Funds, and United Healthcare.

Medicare pays selected practices a per-beneficiary per-month (PBPM) risk-adjusted care management fee, which ranges from $8 to $40. CMS has indicated that it expects care management fees to average $20 PBPM during the first two years of the initiative. In Years 3 and 4, care management fees will average $15 PBPM. Medicare will also introduce a shared savings component beginning in Year 2, calculated at the market level.

The CPCi solicitation for payers indicates that participating payers (non-Medicare) are expected to follow a similar framework, paying per-member per-month (PMPM) care management fees to participating practices on top of fee-for-service and incorporating a shared savings component. Payment amounts will be negotiated individually with participating practices to comply with anti-trust laws.

HealthTeamWorks Multi-payer PilotParticipating HealthTeamWorks pilot sites received enhanced care management and performance-based payments on top of fee-for-service reimbursement.

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: 

  1. Enhanced payments: Connecticut Medicaid will pay participating practices a fee differential payment in addition to the exiting fee schedule, encounter rate or visit rate a practice would normally receive.
  2. Performance payments: Qualified participants will have an opportunity to earn two distinct per member per month performance-based payments: incentive payments and improvement payments. These payments may be risk-adjusted.

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:

  1. Supplemental start-up payments: Small independent practices (defined as having five or fewer full-time equivalent practitioners) whose primary care panel is at least 25 percent Medicaid recipients are eligible to receive start-up infrastructure payments ranging from $13,000 – $25,000. The state will divide start-up payments into three parts, one payment at the start of each Glide Path phase. If a practice fails to achieve NCQA recognition, it must return all supplemental payments it has received.
  2. Enhanced payments: Connecticut Medicaid will pay participating Glide Path practices 50 percent of the fee differential payment paid to fully qualified practices in addition to the exiting fee schedule, encounter rate or visit rate a practice would normally receive. If a practice fails to meet Medicaid’s requirements, enhanced payments will end. However, Connecticut Medicaid will not seek reimbursement for fee differential payments already made.
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.
Idaho Idaho Medical Home Collaborative (IMHC): Participating payers have each developed unique payment methodologies to support participating practices in providing medical home services. Per-member per-month payment amounts for each payer are list below:

  • Idaho Medicaid: $15.50 (see below)
  • Blue Cross of Idaho: $15.50 – $20.00. Payment amounts vary based on practices’ achievement of optional qualification standards above minimum required criteria.
  • Pacific Source: $22.50
  • Regence Blue Shield: $33.00 – $42.00

Participating payers limit payment to patients who qualify based on chronic conditions or medical complexity; to learn more about each payer’s criteria, visit the summary of additional requirements: Blue Cross of IdahoPacific Source, and Regence Blue Shield of Idaho. To learn more Idaho Medicaid, see below.

ACA Section 2703 State Plan Amendment: Medicaid is making payments of $15.50 PMPM to participating health home practices on behalf of qualifying Medicaid participants. Qualifying Medicaid participants include:

  • Patients with serious and persistent mental illness or serious emotional disturbance (pediatric); or
  • Patients with diabetes and asthma; or
  • Patients with diabetes who have or are at risk of having another chronic condition (hypertension, high cholesterol, coronary arterial disease, obesity, or tobacco use); or
  • Patients with asthma who have or are at risk of having another chronic condition (hypertension, dyslipidemia, coronary arterial disease, obesity, or tobacco use).
Illinois Illinois Health Connect pays primary care providers enhanced fee-for-service rates in addition to the following ongoing care management fees:

  • $2.00 per child (under 21) per member per month (PMPM)
  • $3.00 per adult
  • $4.00 per senior or disabled adult

Illinois Health Connect primary care providers are also eligible for performance-based payments. In 2010 years, $3.3 million was been paid for achieving clinical targets.  For 2011 and 2012, bonuses depend on performance in the following six areas:

  • Recommended immunizations
  • Developmental screenings
  • Asthma management
  • Diabetes management
  • Breast cancer screening
  • Lead screening

Information on specific performance targets is available online.

Indiana No known activity at this time.
Iowa IowaCareThe special terms and conditions of the IowaCare 1115(a) waiver waive certain requirement pertaining to the prospective payment system for the federally qualified health centers (FQHCs) serving as IowaCare medical homes. The special terms and conditions also provide for Iowa Medicaid to pay IowaCare sites using the physician fee-for-service methodology. In addition to fee-for-service reimbursement, IowaCare sites receive ongoing care management fees delivered as per member per month (PMPM) payments. The amount of these payments vary:During first 18 months: $3.00 PMPMMedical home recognition below highest level (i.e., National Committee for Quality Assurance (NCQA) Levels 1 or 2): $2.50 PMPMMedical home recognition at highest level of recognition system: $3.50 PMPMPractices without medical home recognition: $1.00 PMPMPractices are also eligible for performance-based payments that are calculated on a PMPM basis but delivered annually. The amount of these potential PMPMs vary as well:During first 18 months: $1.00 PMPMMedical home recognition below highest level: $1.00 PMPMMedical home recognition at highest level: $1.50 PMPM

Practices without medical home recognition: $1.50 PMPM

Practices are judged to be eligible for performance-based payments on the basis of criteria related to:

  • Colon and cervical cancer screenings
  • Documentation of patient body mass index
  • Use of culturally and linguistically appropriate educational materials
  • Tracking of patients referred to the hospital
  • Tracking of patient medications
  • Use of disease registry
  •  Documentation of tobacco use
  •  Immunization administration
  •  Use of HbA1c tests for diabetic patients

Further detail on the performance measures is available on pages 42-43 of the IowaCare 1115(a) waiver.

In addition to these payments, the IowaCare waiver established reimbursement for peer-to-peer provider consultation. This allows remote hospital-based specialists to receive payment for consulting with IowaCare primary care providers.  The consultations are reimbursed at fees ranging from $20.30-$44.37 depending on the length and method of consultation (telephone, e-mail, or video conference). Further details are available on pages 40-41 of the waiver.

ACA Section 2703 Health Homes: Health homes receive a complexity-adjusted per-member-per-month (PMPM) on top of fee-for-service reimbursements for patients with chronic diseases based on a Patient Tier Assessment Tool:

  • Tier 1 (1-3 chronic conditions): $12.80 PMPM
  • Tier 2 (4-6 chronic conditions): $25.60 PMPM
  • Tier 3 (7-9 chronic conditions): $51.21 PMPM
  • Tier 4 (10+ chronic conditions): $76.81 PMPM
Kansas No known activity at this time.
Kentucky No known activity at this time.
Louisiana Under Bayou Health, the Louisiana Department of Health and Hospitals (DHH) is simultaneously implementing two separate models:

  1. Prepaid: Three managed care plans (Amerigroup Louisiana, Inc., Amerihealth Mercy of Louisiana, Inc. and Louisiana Healthcare Connections, Inc.) receive monthly risk-adjusted capitated payments. These plans also receive a lump sum maternity payment for each obstetrical delivery to cover the cost of prenatal and post-partum costs, as well as the delivery and normal newborn hospital costs. The networks are liable for 100% of any costs above the capitation rate. For more information on the reimbursement model or risk-adjustment methodology, please see the Request for Proposal.
  2. Shared Savings: Two managed care plans (Community Health Solutions, Inc. and United Healthcare of Louisiana) receive per-member per-month (PMPM) enhanced primary care case management fees and, if earned, lump sum shared savings payments. For more information, please see the Request for Proposal. The networks are required to pay a portion of their case management fees to primary care providers as a PMPM care coordination payment. Up to 50 percent of the network’s case management fee is subject to repayment to the state if the predetermined savings benchmark is not met.

Both RFPs allow networks to develop performance-based physician incentive plans.

Maine Maine PCMH PilotFor 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. Community Care Teams receive $2.95 PMPM from MaineCare. Medicare fee-for-service will be paying $6.95 PMPM to the practices and $3.00 PMPM to the 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. Commercial plans contribute $0.30 PMPM to Maine’s CCTs. The amount that commercial insurers pay to practices is not publicly available.ACA Section 2703 Health Homes: Health homes receive a $12.00 per-member per-month (PMPM) care management fee in addition to fee-for-service payments. Community care teams receive $129.50 PMPM.
Maryland The five largest commercial payers in Maryland – 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 and $2.89 million in fiscal year 2013 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.” Fixed transformation payments, paid twice a year, facilitate practice-level infrastructure improvements. Practices may also be eligible for “shared savings 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 PopulationPractice sites with fewer than 10,000 patients:Level 1+: $4.68 PMPMLevel 2+: $5.34 PMPMLevel 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 shared savings payments if they meet performance criteria. The performance criteria include measures around evidence-based practices and utilization reduction such as:

  • Blood pressure measurement (also a Centers for Medicare & Medicaid Services (CMS) electronic health record (EHR) meaningful use core measure);
  • Adult Weight Screening and Follow-Up (also a CMS EHR meaningful use core measure);
  • Reduction in 30-day readmission rate;
  • Reduction in number hospital days per 1,000; and
  • Reduction in emergency room visits per 1,000.

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.

The MHCC announced in October 2012 that 23 of the 52 participating pilot practices received shared savings payments from Aetna, CareFirst BlueCross BlueShield, CIGNA, United Healthcare, and Coventry. The total incentive payments, based on 2011 performance metrics and savings, were $815,669.62.

Full details on the payment methodology are available online in the practice participation agreement.

Massachusetts Chapter 224 of the Acts of 2012 requires the newly formed Health Policy Commission to develop a model payment system for certified patient-centered medical homes by January 1, 2014. The commission is required to consider per-patient payments, payments adjusted on patient-complexity; payments for care coordination/clinical management, performance-based payments, and shared savings.Massachusetts Patient-Centered Medical Home Initiative:The following payers and purchasers made enhanced payments through the Massachusetts Patient-Centered Medical Home Initiative (PCMHI):

  • MassHealth Primary Care Clinician (PCC) Plan
  • Health Safety Net
  • Blue Cross Blue Shield of Massachusetts
  • Boston Medical Center HealthNet Plan
  • CeltiCare
  • Fallon Community Health Plan
  • Harvard Pilgrim Health Care
  • Health New England
  • Neighborhood Health Plan
  • Network Health
  • Tufts Health Plan
  • Senior Whole Health
  • UniCare
  • The Health Connector Authority
  • Group Insurance Commission (state employees)

Payers made several types of payments to support participating medical homes prior to the end of PCMHI in April 2014:

  • Start-up payments to practices to support medical home infrastructure: these payments ranged up to $15,000 in the first year of the PCMHI and $3,500 in the second year.
  • Ongoing payment for medical home activities: $1.50 per member per month (PMPM)
  • Ongoing support for clinical care management services: $0.60 PMPM for individuals under age 18, $1.50 PMPM for individuals age 18-64, $6.00 PMPM for individuals age 65 or older
  • Shared savings payments: the payers  agreed to share savings with the participating practices if they generated savings relative to a control group of practices.

Primary Care Payment Reform Initiative (PCPRI): Participating practices receive three types of payments:

  1. Comprehensive Primary Care Payment (CPCP): A risk adjusted per-member per-month (PMPM) payment for primary care services which can include payment for behavioral health services as well.
  2. Quality Incentive Payment: Participating practices receive incentive payments based on fulfilling PCPRI measurement and reporting requirements (“pay for reporting” or P4R); and for performance improvement and/or achieving high quality (“pay for quality performance” or P4Q). Practice performance for calendar year 2012 will serve as a baseline for P4Q.
  3. Shared Savings/Shared Risk Payment: Shared savings and shared risk payments are calculated based on the difference between each participating practice’s target spend – set by the Massachusetts Executive Office of Health and Human Services (EOHHS) – and their actual spend. Participating practices can choose to include long-term services and supports in target and actual spend calculations for the purpose of calculating shared savings and shared risk. Participating practices choose one of three risk tracks on which shared savings payments will be based:
    • Risk Track 1 (Upside/Downside Risk): Practices are eligible to share in savings or losses, and will receive or owe 60% of the difference between their target spend and their actual spend, up to 6% of target spend. Risk Track 1 practices must have at least 5,000 patients enrolled in a MassHealth MCO or the Primary Care Clinician (PCC) Plan, MassHealth’s Primary Care Case Management program.
    • Risk Track 2 (Transitioning to Downside Risk): In Year 1, practices are eligible for shared savings only, using the Risk Track 3 methodology for calculating savings and distributing payments (see below). In Year 2, practices are eligible to share in savings or losses, and will receive or owe 60% of the difference between their target spend and their actual spend, up to 6% of target spend for shared savings and up to 3% of target spend for shared losses. In Year 3, practices will transition fully shared savings and risk, using the Risk Track 1 methodology. Risk Track 2 practices must have at least 5,000 patients enrolled in a MassHealth MCO or the PCC Plan.
    • Risk Track 3 (Upside Risk Only): Practices are eligible to share in up to 50% of savings. The proportion of savings paid to practices varies based on the level of savings. Practices that produce greater savings (the difference between actual spend and target spend as a percentage of target spend) are eligible for a greater share of savings. Risk Track 3 practices must have at least 3,000 patients enrolled in a MassHealth MCO or the PCC Plan.

For more information on how the state plans to calculate CPCP, quality incentive, and shared savings/shared risk payments, including target spend and actual spend, see Attachement A of the PCPRI RFA.

Practice performance on 23 quality measures that will also impact P4R (all years), P4Q (Years 2-3), and SS (Year 3 only) payments. For more information on the selected measures, including impact on payment, see Attachement D of the PCPRI RFA.

Michigan Since January 2012, participating practices and providers in the Michigan Primary Care Transformation (MiPCT) Project have received three per-member per-month (PMPM) payments for each attributed patient:

  • Care coordination payment – $3.00 PMPM ($4.50 for Medicare)
  • Practice transformation payment – $1.50 PMPM ($2.00 for Medicare)
  • Performance incentives – $3.00 PMPM
Minnesota As per Minnesota law, state-regulated payers (including Medicaid managed care plans) 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:

  1. State employee group insurance
  2. Blue Plus (Blue Cross Blue Shield of Minnesota)
  3. HealthPartners
  4. Itasca Medical Care
  5. Medica
  6. Metropolitan Health Plan
  7. Preferred One
  8. Primewest Health
  9. South County Health Alliance
  10. UCare Minnesota

In order to receive enhanced reimbursement, practices must actively identify patients as qualifying members of their panel. According to the state plan amendment authorizing the Medicaid payment methodology, payments are tiered based on the number of “major condition groups” (i.e., cardiovascular, respiratory, neurologic, renal, etc.) within which a patient has a severe, chronic condition requiring a care team.

  • Tier 1 (1-3 major condition groups): $10.14 per-member per month (PMPM) payment
  • Tier 2 (4-6 major condition groups): $20.27 PMPM
  • Tier 3 (7-9 major condition groups): $40.54 PMPM
  • Tier 4 (10+ major condition groups): $60.81 PMPM

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%.

Mississippi No known activity at this time.
Missouri ACA Section 2703 Health Homes – 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.ACA Section 2703 Health Homes – Primary Care Health Homes:Primary care health homes receive clinical care management payments totaling $58.87 per-member per-month to fund the services of nurse care managers, behavioral health consultants, and care coordination and administration support staff.MOHealthNet will review the payment methodology for both groups of health home providers after 18 months and explore whether tiered payments are appropriate. Payments will be  adjusted annually according to the consumer price index. Payments for health home enrollees participating in a managed care plan will be made directly from Medicaid to the health home provider.
Montana The Montana Commissioner of Securities and Insurance promulgated regulations setting the payment standards for the Montana Patient-Centered Medical Home Program.The regulations stipulate that medical home payment models are required to support enhanced primary care, and payers may select from the following approved payment methodologies:

  • Payment for PCMH recognition/certification/accreditation;
  • Reimbursement for care coordination, care management, disease management, population health, behavioral health specialist, and clinical pharmacist services;
  • Payment for quality improvement;
  • Shared Savings; or
  • Block grants to support medical home capabilities.

Payers may adopt alternative payment methodologies that support the intent of the program subject to the Commissioner of Securities and Insurance’s approval.

Specifically, Medicaid pays an additional per-member per-month (PMPM) payment ranging from $3.33 to 15.33 depending on patient acuity. The commercial payers have taken various approaches, including new fee-for-service codes, PMPM payments, shared savings, performance-based payment, and lump-sum grants. Additional information for each payer follows: Allegiance Benefit Plan Management, Inc.; BlueCross BlueShield of Montana; PacificSource Health Plans.

Nebraska Nebraska Medicaid Patient-Centered Medical Home PilotNebraska developed a unique payment structure to support medical homes through the Nebraska Medicaid Patient-Centered Medical Home Pilot, a two-year pilot which launched in February 2011 and ran through February 2013. Upon signing a participation agreement with the Nebraska Department of Health and Human Services (DHHS), practices were paid $2.00 per member per month (PMPM). This PMPM rate increased to $4.00 upon achievement of Tier 1 recognition. Practices that chose to continue medical home transformation to meet the more advanced Tier 2 standards received 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.Multi-Payer Patient-Centered Medical Home Pilot: The participation agreement for Nebraska’s multi-payer medical home pilot does not require payers and practices to use a specific payment methodology. Instead, it puts forward broad requirements for payment agreements between participating payers and practices:

  • Payments must be value-based and go beyond the fee-for-service system.
  • Payments should be linked to practice performance (clinical, financial, and/or patient satisfaction).
  • Payments should not be limited to patients with a specific condition or set of conditions; instead, practices should be paid on behalf of their full panel of covered patients.
Nevada No known activity at this time.
New Hampshire No known activity at this time.
New Jersey New Jersey Medicaid Medical Home Demonstration Project: 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 contractstates 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.”Comprehensive Primary Care Initiative (CPCi): This four-year multi-payer initiative, launched in November 2012, includes six payers in the New Jersey market: Medicare, Amerigroup, AmeriHealth New Jersey, Horizon Blue Cross Blue Shield of New Jersey, and UnitedHealthcare.Medicare pays selected practices a per-beneficiary per-month (PBPM) risk-adjusted care management fee, which ranges from $8 to $40. CMS has indicated that it expects care management fees to average $20 PBPM during the first two years of the initiative. In Years 3 and 4, care management fees will average $15 PBPM. Medicare will also introduce a shared savings component beginning in Year 2, calculated at the market level.The CPCi solicitation for payers indicates that participating payers (non-Medicare) are expected to follow a similar framework, paying per-member per-month (PMPM) care management fees to participating practices on top of fee-for-service and incorporating a shared savings component. Payment amounts will be negotiated individually with participating practices to comply with anti-trust laws.
New Mexico 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.
New York Adirondack Medical Home DemonstrationParticipating 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 ProgramNCQA-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):

  • Level 1: $5.50
  • Level 2: $11.25
  • Level 3: $16.75

Office-based practitioners:

  • Level 1: $7.00
  • Level 2: $14.25
  • Level 3: $21.25

Medicaid discontinued payments to Level 1 NCQA PCMH providers in December 2012. The state announced in May 2013 that it would discontinue payments to practices recognized as Level 2 under the NCQA 2008 standards and reduce payment to practices recognized as Level 3 under the 2008 standards in July 2013.

Managed care plans pay a per-member per-month (PMPM) incentive payment for each participating enrollee. This payment is also tiered by NCQA recognition:

  • Level 1: $2.00 PMPM
  • Level 2: $4.00 PMPM
  • Level 3: $6.00 PMPM

ACA Section 2703 Health Homes: Health homes receive a risk-adjusted per-member per-month care management fee that varies based on geography and case mix. Fees range from $75-$390. Health homes are paid the full PMPM rate for patients in the “active care management group” (those who are fully enrolled and have been assigned a care manager who have received at least one core health home service during the quarter), or 80% of the PMPM rate for up to six months for eligible patients in the “case finding group” (patients identified as eligible and attributed to a health home but not yet enrolled or assigned a care manager).

Comprehensive Primary Care Initiative (CPCi): This four-year multi-payer initiative, launched in November 2012, includes seven payers in New York’s Capital District-Hudson Valley market: Medicare, Aetna, Capital District Physicians’ Health Plan, Empire Blue Cross, Hudson Health Plan, MVP Health Care, and Teamsters Multi-Employer Taft Hartley Funds.

Medicare pays selected practices a per-beneficiary per-month (PBPM) risk-adjusted care management fee, which ranges from $8 to $40. CMS has indicated that it expects care management fees to average $20 PBPM during the first two years of the initiative. In Years 3 and 4, care management fees will average $15 PBPM. Medicare will also introduce a shared savings component beginning in Year 2, calculated at the market level.

The CPCi solicitation for payers indicates that participating payers (non-Medicare) are expected to follow a similar framework, paying per-member per-month (PMPM) care management fees to participating practices on top of fee-for-service and incorporating a shared savings component. Payment amounts will be negotiated individually with participating practices to comply with anti-trust laws.

North Carolina Community Care of North Carolina (CCNC)Currently, Community Care of North Carolina (CCNC) providers and networks both receive per-member per-month (PMPM) payments for each patient under their care in addition to fee-for-service reimbursement.CCNC providers receive:

  • Aged, Blind and Disabled (ABD) population: $5.00 PMPM
  • Non-ABD population: $2.50 PMPM

CCNC Networks receive:

  • ABD population: $13.72 PMPM
  • Non-ABD population: $3.72 PMPM

Networks return $3.17 and $0.54 monthly for each ABD and non-ABD enrollee to support the central office.

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.

ACA Section 2703 Health Homes: North Carolina’s health homes program pays practices and networks using the same methodology as the Community Care of North Carolina program, described above.

Medicare Advanced Primary Care Practice (MAPCP)Demonstration: Payments to participating practices vary by payer:

  • Medicare: $2.50-$3.50 in addition to fee-for-service. Payments vary based on level of NCQA PCMH recognition: practices with Level 1 recognition receive $2.50; Level 2 practices receive $3.00; and Level 3 practices receive $3.50.
  • North Carolina Medicaid: Medicaid payments are consistent with the CCNC payment methodology, described above.
  • Blue Cross Blue Shield of North Carolina (BCBSNC) and State Health Plan (administered by BCBSNC): Practices receive enhanced fee-for-service payments for Evaluation & Management codes. Enhanced payments begin when a practice submits its application for NCQA PCMH recognition.
  • Participating CCNC networks in counties also receive per-member per-month payments from each participating payer. See CCNC’s MAPCP Frequently Asked Questions page for more information on how payments are made.
North Dakota No known activity at this time.
Ohio PCMH Education Pilot Project: Substitute House Bill 198 (128thGeneral 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.ACA Section 2703 State Plan Amendment – Community Behavioral Health Centers (CBHCs): Participating practices will receive a monthly case rate. Rates will varey by health home based on caseload and dedicated health home staffing costs for each qualifying enrollee.CMS’s Comprehensive Primary Care Initiative (CPCi): This four-year multi-payer initiative, launched in October 2012, includes ten payers in the Cincinatti-Dayton market: Medicare, Ohio Medicaid, Aetna, Amerigroup, Anthem Blue Cross Blue Shield Ohio, CareSource, Centene Corporation, Humana, HealthSpan, Medical Mutual, and UnitedHealthcare.Medicare pays selected practices a per-beneficiary per-month (PBPM) risk-adjusted care management fee which ranges from $8 to $40. CMS has indicated that it expects care management fees to average $20 PBPM during the first two years of the initiative. In Years 3 and 4, care management fees will average $15 PBPM. Medicare will also introduce a shared savings component beginning in Year 2, calculated at the market level.The CPCi solicitation for payers indicates that participating payers (non-Medicare) are expected to follow a similar framework, paying per-member per-month (PMPM) care management fees to participating practices on top of fee-for-service and incorporating a shared savings component. Payment amounts will be negotiated individually with participating practices to comply with anti-trust laws.
Oklahoma SoonerCare ChoiceSoonerCare Choice utilizes multiple payments to incentivize practice transformation. These payments include:

  • Quarterly per-member “transitional” payments to support practice transformation (only available during the first year of the program);
  • Traditional fee-for-service reimbursement for visits*;
  • A tiered per member per month (PMPM) care management payment that ranges from $3.03 to $8.69; and
  • Quarterly SoonerExcel performance-based incentive payments.

*Providers can use additional codes to bill for enhanced reimbursement when providing care outside of normal business hours.

Comprehensive Primary Care Initiative (CPCi): This four-year multi-payer initiative, launched in October 2012, includes four payers in the Tulsa market: Medicare, Oklahoma Health Care Authority, CommunityCare, Blue Cross and Blue Shield of Oklahoma.

Medicare pays selected practices a per-beneficiary per-month (PBPM) risk-adjusted care management fee, which ranges from $8 to $40. CMS has indicated that it expects care management fees to average $20 PBPM during the first two years of the initiative. In Years 3 and 4, care management fees will average $15 PBPM. Medicare will also introduce a shared savings component beginning in Year 2, calculated at the market level.

The CPCi solicitation for payers indicates that participating payers (non-Medicare) are expected to follow a similar framework, paying per-member per-month (PMPM) care management fees to participating practices on top of fee-for-service and incorporating a shared savings component. Payment amounts will be negotiated individually with participating practices to comply with anti-trust laws. Payments from the Oklahoma Health Care Authority for providers caring for Medicaid enrollees in CPCi are as for SoonerCare Choice mentioned above.

Oregon Oregon Patient-Centered Primary Care Home (PCPCH) Programand ACA Section 2703 Health HomesChapter 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.With approval of Oregon’s state plan amendment to implement Section 2703 Health Homes for Medicaid enrollees with chronic health conditions, recognized PCPCH health homes will receive per-member per-month payments of $10, $15, or $24 for health home enrollees, provided that the health home provides a core health home service for that enrollee at least once per quarter. Payment amounts vary based on PCPCH tier.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:

  • Valuing services performed by nurses and behaviorists;
  • Payment for the establishment and use of team-based care
  • Preventive, educational, diagnostic care, care management and follow-up social services coordination; and
  • Home visits for case management services

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:

  • Integrating primary, oral and behavioral health care;
  • Utilizing evidence-based best practices;
  • Improving health outcomes; and/or
  • Learning collaborative participation.

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:

  • Provide financial support for meeting PCPCH standards;
  • Recognize the three levels of PCPCH tiering; and
  • Base reimbursement on the quality rather than the quantity of services provided.

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:

  • Electronic medical record implementation and upgrade;
  • Care coordination; and
  • Dedicated time to quality improvement.

Comprehensive Primary Care Initiative (CPCi): This four-year multi-payer initiative, launched in November 2012, includes seven payers in the Oregon market: Medicare, Oregon Health Authority, CareOregon, Providence Health Plans, Regence BlueCross BlueShield, Teamsters Multi-Employer Taft Hartley Funds, and Tuality Health Alliance.

Medicare pays selected practices a per-beneficiary per-month (PBPM) risk-adjusted care management fee, which ranges from $8 to $40. CMS has indicated that it expects care management fees to average $20 PBPM during the first two years of the initiative. In Years 3 and 4, care management fees will average $15 PBPM. Medicare will also introduce a shared savings component beginning in Year 2, calculated at the market level.

The CPCi solicitation for payers indicates that participating payers (non-Medicare) are expected to follow a similar framework, paying per-member per-month (PMPM) care management fees to participating practices on top of fee-for-service and incorporating a shared savings component. Payment amounts will be negotiated individually with participating practices to comply with anti-trust laws.

Pennsylvania 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. From 2009 to 2011, the state’s contracts with Medicaid managed care organizations (MCOs)  required MCOs to participate in  CCI; this requirement was removed prior to the start of CCI Phase II in January 2012.Under Phase II, practices 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:

  1. All practices are receiving “Physician Coordinated Care Oversight Services” PMPMs. The amounts are as follows:
  • Year 1: $1.50
  • Year 2: $1.28
  • Year 3: $1.08
  1. Practices are receiving “Coordinated Care Fees” that vary by patient age. These PMPMs are intended to provide funding for care coordinators.
  • The amounts are as follows for those age 18 or younger:

Year 1: $0.60
Year 2: $0.51
Year 3: $0.43

  • The amounts are as follows for those age 19-64:

Year 1: $1.50
Year 2: $1.28
Year 3: $1.08

  • The amounts are as follows for those age 65-74:

Year 1: $5.00
Year 2: $4.25
Year 3: $3.61

  • The amounts are as follows for those age 75 or older:

Year 1: $7.00
Year 2: $5.95
Year 3: $5.06

Practices are eligible for shared savings payments that will take into consideration practice performance on key quality metrics, including diabetes and hypertension management, as well as utilization and cost metrics. As the PMPM amounts decrease from Year 1 to Year 3, practices will be eligible for greater shares of any savings: 40% in Year 1, 45% in Year 2, and 50% in Year 3.

Rhode Island The Care Transformation Collaborative of Rhode Island (CTC): Under a new common developmental contract, participating practices receive a base payment of $5.50 per-member-per-month (PMPM) to fund practice transformation and nurse care management. As practices transform, payment can increase or decrease based on meeting specific performance targets related to NCQA recognition, utilization, quality and patient experience (max payment: $8.75 PMPM). Detailed information on the payment methodology can be found on page 10 of this PDF.

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.

ACA Section 2703 Health Homes – CEDARR Family Centers: CEDARR Family Centers receive federal match for three distinct bundled services: initial family intake and needs assessment ($366); family care plan development ($347); and family care plan review ($397). Centers may also bill for health needs coordination and therapeutic consultation; rates vary based on coordinators’ education level.

ACA Section 2703 Health Homes – Community Mental Health Organizations (CMHOs): Participating CMHOs receive $442.21 PMPM for providing enhanced health home services for members with serious and persistent mental illness.

ACA Section 2703 Health Homes – Opioid Treatment Programs (OTPs): OTPs receive a weekly bundled rate ($87.52 fee-for service; $52.52 RIte Care) for each patient based on staffing costs to provide the health homes services.

South Carolina Care Coordination Service Organizations (CSO), administrative entities that contract with primary care physicians in a Medical Home Network, receive two payments for their services:

  1. Monthly Care Coordination Fees: Networks receive monthly care coordination fees equal to $10 per member per month (PMPM).
  2. Shared Savings: Networks that save money can earn shared savings payments of 50 percent of the actual savings (up to a maximum of five percent of the total fee for service payments incurred by network enrollees). The South Carolina Department of Health and Human Services calculates costs and savings quarterly.

Networks that do not achieve savings risk a penalty that would require the network to return a portion (or all) of their prospective care coordination fees.

It is up to each CSO to determine specific care coordination fees and shared savings payments made to the participating primary care providers in their network. Care coordination fees to providers are paid out of the network’s $10 PMPM payment.

Participating providers continue to receive fee for service reimbursement from South Carolina Medicaid; the Medical Home Networks do not pay any claims.

South Dakota No known activity at this time.
Tennessee No known activity at this time.
Texas No known activity at this time.
Utah 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.
Vermont Practices receive enhanced per-member per-month (PMPM) payments in addition to fee-for-service reimbursement. Payments vary by NCQA PCMH recognition year and score, from $1.20 to $2.39 for practices with 2008 NCQA recognition and from $1.36 to $2.39 for practices with 2011 NCQA recognition.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 MAPCPdemonstration, Vermont subsidized Medicare’s share of payments.
Virginia The Virginia Department of Medical Assistance Services’ (DMAS) contracted Medicaid managed care organizations (MCOs) are establishing quality benchmarks that will help determine provider rewards. The MCOs have communicated that they will base initial goals on the measures selected by DMAS for its quality improvement program.
Washington Payer participation in Washington State’s mutli-payer Patient Centered Medical Home (PCMH) Pilot, which ran for 32 months from May 2011 through December 2013, was voluntary. The following payers joined the program on behalf of their commercial, Medicaid managed care, Medicare Advantage, and Basic health lines of business:

  • Premera
  • Regence
  • Group Health
  • Aetna
  • CIGNA
  • United Health Care
  • Molina Health Care
  • Community Health Plan of Washington

For the duration of the Pilot, participating practices received per member per month (PMPM) payments and were be eligible for shared savings payment if they reduce avoidable acute care utilization. The amount of the PMPM payment was set at $2.50 initially; it decreased to $2.00 PMPM after the first nine months. If practices did not achieve savings greater than or equal to the total amount of PMPM payments, they were accountable for paying back up to half of the PMPM payments through reductions in future PMPM payment rates. 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.

West Virginia Providers and payers that participated 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 was voluntary. The following payers participated:

  • UniCare (Medicaid managed care)
  • Highmark Blue Cross Blue Shield
  • Public Employees Insurance Agency (state employees)
Wisconsin Wisconsin pays AIDS Service Organizations participating in the state’s ACA Section 2703 Health Homes program a monthly case rate for care management activity and an annual fee for completing an assessment and developing or updating a care plan.
Wyoming Beginning in April 2015, The Wyoming Department of Health will pay medical homes an extra $3 per-member per-month. In order to receive payment, practices must:

  1. Participate in WyHealth, a care management program for Medicaid enrollees;
  2. Attest to implementing core medical home functions, based on NCQA PCMH standards.
  3. Pull continuity of care documents for at least half of their Medicaid patients from the state’s health information exchange on a quarterly basis, and
  4. Submit nine clinical quality measures into the State Level Registry on a monthly basis.

Leave a Reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>

WordPress spam blocked by CleanTalk.