Connecticut – Medical Homes

In January 2012, Connecticut introduced a person-centered medical home (PCMH) initiative within their redesigned HUSKY Health program. Under this initiative, Connecticut Medicaid provides new payment incentives to practices and clinics that demonstrate a higher standard of person-centered medical care. In order to receive enhanced payments for medical home services, providers must be an active licensed physician, nurse practitioner or physician’s assistant specializing in general internal medicine, geriatrics, family medicine or general pediatrics that functions as a primary care provider for a set panel of patients. Furthermore, primary care must account for 60 percent of the practitioner’s time across all payers.

Connecticut is offering additional support to practices that would not currently receive Level 2 or Level 3 NCQA PCMH recognition, a requirement to receive full payment incentives. Under a “Glide Path” option, practices can participate in a three-phase program that requires them to meet specific milestones that prepares the practice to achieve NCQA recognition. Each phase lasts six months, and practices can take extensions totaling an additional six months. Glide Path practices that fail to achieve NCQA Level 2 or Level 3 recognition within 24 months are no longer qualified to participate in the Glide Path program.

The PCMH initiative is one of several Husky Health reforms, which also includes expanded eligibility to the Aged, Blind, and Disabled (ABD) population and low-income adults. HUSKY Health has already been serving low-income families and Children’s Health Insurance Program (CHIP) enrollees. HUSKY Primary Care, Connecticut’s pilot primary care case management (PCCM) program for low-income families, concluded at the start of 2012. Additional information on the medical home initiative can be found in provider bulletins 2011-77 and 2011-84, as well as the provider application.

Also, Connecticut Public Act 09-148 established the SustiNet Health Partnership, which is tasked with designing and implementing a new public health insurance program for residents who are not eligible for Medicare or Medicaid and are not offered employer-based coverage. This law included multiple references to medical homes, including a statutory PCMH advisory committee and a mandate that medical home services be included in the standard benefits package. More information can be found in the advisory committee’s final report and a 2011 Legislative Report.

Furthermore, in 2009, the Connecticut state comptroller included a PCMH pilot component in the State Health Plan re-procurement process. The state has partnered with ProHealth Physicians to provide 35,000 individuals covered under the state employee health program access to NCQA-recognized medical homes.
Federal Support: Connecticut has received a duals demonstration grant from the Centers for Medicare & Medicaid Services (CMS) to “coordinate care across primary, acute, behavioral health and long-term supports and services for dual eligible individuals.”

Last Updated: April 2014

Forming Partnerships
Minutes from the Medicaid Medical Assistance Program Oversight Council show that the following groups provided input during the development of the Connecticut medical home initiative:
  • Medicaid Medical Assistance Program Oversight Council
  • A Primary Care Case Management Sub-committee
  • A Provider Advisory Workgroup
  • A Pediatric Workgroup
  • Consumers
  • Advocates
  • Providers
  • Payers
The Connecticut Department of Social Services also hosted five public forums for HUSKY Health enrollees across the state.
Furthermore, Connecticut Public Act 09-148 required the SustiNet Health Partnership to include a Patient Centered Medical Home Advisory Committee composed of physicians, nurses, consumer representatives and other selected qualified individuals. The advisory committee is charged with developing proposed regulations for the administration of medical homes serving SustiNet enrollees.
Defining & Recognizing a Medical Home
Recognition: Participating medical homes must meet Level 2 or Level 3 NCQA medical home recognition standards (2008 or 2011, depending on time of NCQA application).
Additionally, Connecticut mandates that medical home practices must:
  • Meet Federal Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) requirements;
  • Participate in a specific smoking cessation incentive program;
  • Participate in initiatives to decrease racial and ethnic health disparities; and
  • Adhere to consumer protection standards.
Practices that choose the Glide Path option will participate in a structured program that culminates in NCQA Level 2 or Level 3 recognition. The purpose of this option is to assist practices that would not currently receive Level 2 or Level 3 NCQA PCMH recognition, a requirement to receive full payment incentives. Practices choosing this option progress through three phases:
Phase I: Practices must meet three of the following requirements:
  1. NCQA Level 1 recognition;
  2. Receipt of Medicaid electronic health record (EHR) incentive payments;
  3. Orientation of clinical and non-clinical staff to medical home requirements and strategies to meet medical home requirements;
  4. Ongoing monthly learning activities for clinical and non-clinical staff; or
  5. Documentation for the adoption/implementation of a new Meaningful Use Certified EHR OR development of a workplan to upgrade an existing EHR to meet Meaningful Use Certification.
Phase II: Practices must meet three of the following requirements:
  1. Use of a Meaningful Use Certified EHR for electronic prescribing, problem list generation, medication management, and progress note generation;
  2. A contract with the eHealth Connecticut Regional Extension Center with the goal of becoming a meaningful user of an EHR;
  3. Employ or contract care coordination and disease education resources;
  4. Use of an EHR or registry to identify and serve patients with chronic conditions; or
  5. Enhanced access to clinical sites (including expanded hours and/or electronic communication)
Phase III: NCQA Level 2 or Level 3 recognition.
Practices have six months to complete each phase of the program. However, practices may take extensions totaling no more than six additional months. If a practice does not receive NCQA Level 2 or Level 3 recognition within 24 months from the start of their participation, the practice is no longer qualified to participate in the Glide Path.
Aligning Reimbursement & Purchasing
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. For a summary of this reimbursement model, see the state’s PCMH Reimbursement Summary.
NCQA Level 2 or Level 3 practices: 
  1. Enhanced payments: Connecticut Medicaid will pay participating practices a fee differential payment in addition to the existing 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 a percentage 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.
Supporting Practices
Connecticut Medicaid and the Community Health Network of Connecticut, the HUSKY Health administrative services organization, are providing the following practice supports:
  • Referral assistance and appointment scheduling;
  • Provider recruitment;
  • Health education;
  • Utilization management including prior authorization (including a web portal to request authorizations);
  • Case management including intensive care management;
  • Quality management; and
  • Health data analytics and reporting
In addition, Connecticut Medicaid is also providing financial incentives to “Glide Path” practices seeking NCQA medical home recognition to help with start-up transformation costs.
Measuring Results
As part of the incentive and performance improvement payments, Connecticut will track a number of specific pediatric and adult outcome and process measures. These measures include:
Adult:
  • Number of diabetics receiving blood pressure screenings and eye exams
  • Inpatient readmissions
  • Emergency department utilization
  • Medication reconciliation for asthmatics
Pediatric:
  • Developmental Screenings
  • Recommended well-care visits
  • Connection to dental services
  • Emergency department utilization
Customized CAHPS-PCMH surveys for both the adult and pediatric populations will include questions to evaluate patient experience with medical homes and the Medicaid provider network.