Considerations for States Interested in Applying for the States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model
In September 2023, the Centers for Medicare & Medicaid Services (CMS) announced its latest total cost-of-care model, the States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model, with the goals of slowing growth in health care costs, improving population health, and advancing health equity (see NASHP’s summary of the model).
Participation is competitive, with up to eight states selected to participate across three cohorts. While the application periods for Cohorts 1 and 2 are closed, states can submit applications by August 12, 2024, for consideration for Cohort 3. Specifics required for the applications can be found in the Notice of Funding Opportunity (NOFO), responses to FAQs, and additional information on the CMS Model website.
This blog post summarizes both the Primary Care AHEAD requirements identified by CMS and additional strategic considerations for states. It is part of a series highlighting key components of the AHEAD Model for states. See the first blog post in the series covering governance and the second blog post describing hospital global budgets.
Primary Care AHEAD Overview and Requirements
Primary Care AHEAD is a key component of the AHEAD Model. The overarching goals of Primary Care AHEAD are to help states participating in the model increase investments in primary care as a percent of the total cost of care (TCOC) for Medicare fee-for-service (FFS) (link downloads Excel file) and across all payers and to support advanced primary care initiatives through capacity-building efforts among a range of practice types.
Primary Care AHEAD is designed to be tailored to states’ primary care goals within their Medicaid programs, while aligning these goals with Medicare’s primary care strategy that incorporates investments from Medicare. A core aspect is a focus on alignment between payers. Medicaid is required to participate by performance year one, and CMS encourages commercial payer participation and Medicare Advantage alignment.
Enhanced Primary Care Payments
While primary care practices in AHEAD Model states are not required to participate in Primary Care AHEAD, the model incentivizes their participation through Medicare FFS Enhanced Primary Care Payments (EPCP) to small and large practices to facilitate investment in advanced primary care, enhanced care management, and behavioral health integration.
Specifically, EPCPs will provide participating practices with an average of $17 per Medicare FFS beneficiary per month (PBPM) for attributed beneficiaries, with no minimum number of beneficiaries required. A small portion of the EPCP is at risk for quality performance (initially five percent), and at the provider level, CMS will apply beneficiary risk adjustments. Also, states may earn a higher (a maximum of $21) or lower (a floor of $15) PBPM depending on hospital recruitment for global budgets or state TCOC performance.
Practices must meet the following eligibility criteria to receive the Medicare FFS EPCP:
- Be one of the permitted practice types:
- Independent primary care practices, including small practices with primary care specialties defined by CMS (link downloads Excel file).
- Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs)
- Hospital-owned practices (eligible to participate only if the affiliated hospital is participating in the AHEAD hospital global budget for that performance year with an exception for hospital-owned FQHCs and RHCs).
- Practices participating in the Medicare Shared Savings Program (MSSP) or the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) (CMS released guidance on model overlaps with these and other programs and AHEAD.)
- Participate in the state’s Medicaid primary care alternative payment model (APM): The APM can include a patient-centered medical home (PCMH) program, a health home initiative, a related type of care coordination program, or an additional value-based payment arrangement.
- Engage in specific care transformation requirements: Practices will be required to meet certain care transformation requirements.
Care Transformation Requirements
Practices must engage in the following specific care transformation requirements as part of Primary Care AHEAD:
- Integrate behavioral health care as a function of primary care
- Enhance care management and specialty coordination
- Address health-related social needs (HRSNs) of beneficiaries
Practices can use the EPCP to promote relationships with specialty providers or offer care connections through e-consults or other referrals. Related to addressing HRSNs, practices could provide links to community-based services or opt to hire community health workers.
Quality Measures
Specific care transformation requirements and prioritized quality measures will be selected based on the advanced primary care transformation and quality priorities that already exist in the state’s Medicaid program, so they could differ from those within Medicare.
Practice Agreements
Participating practices must sign an agreement with CMS prior to the first performance year in which they plan to participate. This agreement will outline the state and community context for primary care, the specific needs of a practice’s attributed Medicare FFS and Medicaid lives, and the state’s specific care transformation efforts.
Primary Care AHEAD Key Considerations for States
States that are interested in pursuing the AHEAD Model should consider and assess various factors within their state-specific health system landscape to evaluate how Primary Care AHEAD will align with their current health care transformation efforts.
Assessment of Current State Primary Care Transformation and Medicaid APM Efforts
States must clearly delineate the state’s overall vision for primary care transformation in the application narrative. State applicants will want to consider factors such as the status of primary care and behavioral health integration within practices, the types of existing supports that can facilitate these efforts, and/or any barriers that could impede implementation of more integrated care. States may also want to identify ways to ensure that practices have the capacity to make connections to community resources to address HRSNs for both Medicare FFS and Medicaid beneficiaries.
Additionally, states applying for the AHEAD Model must identify whether there is an applicable Medicaid primary care APM and/or a related model such as a PCMH already in place that meets the AHEAD Model’s requirements. This includes an assessment of the types of practices already engaged in the state’s Medicaid primary care APM for an adequate and well-balanced mix of practices and to determine whether there are any service gaps for addressing HRSNs that could involve other partners such as community organizations. States must also determine what type of regulatory or legislative authority they will need to implement a new Medicaid primary care APM or any necessary revisions to the state’s current Medicaid primary care APM, such as any updates to existing waivers, new waivers, or state plan amendments.
For states that already have capitation programs for primary care in Medicaid, CMS indicated that it will offer new tracks for 2027 to incorporate an option for a Medicare primary care capitated track.
States should also evaluate whether primary care practices are participating in commercial APMs. To incentivize participation and avoid burdens for primary care providers, states may want to ensure that models align across payers so that providers can meaningfully participate in advancing primary care.
Finally, states that are at the forefront on primary care investment and associated quality measures may want to consider proposing existing state primary care quality measures that meet their primary care goals and align with the Primary Care AHEAD measures in the NOFO.
Engagement and Support of Practices
Practice recruitment: States should develop a practice recruitment plan, a key component of the model application for the Medicaid Primary Care APM. States should think about factors that will incentivize practices to participate in the Medicaid Primary Care APM and Primary Care AHEAD to ensure a well-balanced mix of practices and payers, including FQHCs and RHCs.
Assessing existing practice agreements: Because Primary Care AHEAD quality measures may differ from current quality measures, and because a state may alter its existing Medicaid APM or develop a new Medicaid primary care APM to ensure alignment with its overall goals, states should ensure their Medicaid practice agreements align with the Medicaid APM, Primary Care AHEAD, and commercial payer agreements. States should ensure they can track their Medicaid APM practice agreements and Primary Care AHEAD practice agreements with CMS as practices enter and exit the program.
Technical assistance for practices: States should consider the types of ongoing support and technical assistance that may be offered to participating practices. Practices may need support for quality measure reporting, data collection, or other requirements. While CMS will provide technical assistance to practices, states may consider ways to support practices and determine how reporting functions can be streamlined to minimize the burden on practices, particularly for smaller practices and/or those lacking the technical experience and capacity for reporting.
Other State-Specific Factors
Potential state payment reforms: For states considering risk arrangements, up to and including partial or full capitation of primary care payments, some practices will require additional details about these payment reform plans before agreeing to participate in Primary Care AHEAD.
Assessing state statutes for potential implementation barriers: States applying for the AHEAD Model should assess whether existing state statutes could potentially create barriers for Primary Care AHEAD implementation, such as laws related to provider reimbursements or other existing regulations related to primary care payment and delivery.
Overall, it is important for states to consider how Primary Care AHEAD program activities will align with other aspects of the AHEAD Model, such as hospital global budgets, to achieve improvements in quality and access over the course of the model period and increases in primary care investments. Learn more about Primary Care AHEAD from a recent CMS webinar, “The Role of Primary Care in the AHEAD Model.”
Next Steps
States that are exploring or interested in applying for Cohort 3 can reach out to NASHP for technical assistance.
