Criteria for Participation

Criteria for participation in the accountable care activity include specific requirements set forth by the state in regulations, requests for proposals, managed care contracts, and other official policy statements. This includes patient protection requirements around notification and grievance resolution.

 

Alabama
Act 2013-261 requires the Medicaid agency to establish by rule the criteria for certification of Regional Care Organizations (RCOs).
 
Since RCOs will provide Medicaid services to Medicaid enrollees directly or by contract with other providers, the certification standards will include service delivery network requirements: each RCO will be required to establish an adequate medical service delivery network as determined by the Medicaid agency. An alternate care provider contracting with Medicaid shall also establish such a network.
Alaska No known activity at this time.
Arizona No known activity at this time.
Arkansas

The Arkansas Health Care Payment Improvement Initiative includes all providers who provide care for Medicaid, Arkansas BlueCross BlueShield, and Arkansas QualChoice; participation is mandatory.

California
Participation in the California Public Employees’ Retirement System (CalPERS) accountable care organization pilot is limited to a specific hospital chain and physician group.
 
Participating providers agreed to hold 2010 costs for participating members no higher than 2009 levels, without sacrificing quality or patient satisfaction.
Colorado  

Colorado’s Department of Health Care Financing and Policy selected seven Regional Care Collaborative Organizations (RCCOs) through an RFP process in 2010.

 

Enrolled Medicaid providers who wish to become Primary Care Medical Providers in the Accountable Care Collaborative (ACC) Program must meet one of the following criteria:

 

 

  • Certified by the Department as a provider in the Medicaid and CHP+ Medical Homes for Children program; OR
  • A Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC) or a clinic or other group practice with a focus on primary care, general practice, internal medicine, pediatrics, geriatrics, or obstetrics and gynecology; OR
  • An individual physician, advanced practice nurse or physician assistant with a focus on primary care, general practice, internal medicine, pediatrics, geriatrics, or obstetrics and gynecology

 

Furthermore, Primary Care Medical Providers must commit to nine additional principles that ensure care is patient/family-centered; whole-person oriented and comprehensive; coordinated and integrated; provided in partnership with the patient and promotes patient self-management; outcomes-focused; consistently provided by the same provider as often as possible so a trusting relationship can develop; and provided in a culturally competent and linguistically sensitive manner.

Connecticut No known activity at this time.
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 Participation in the Accountable Healthcare Alliance of Rural Oahu (AHARO) is currently limited to the three Federally Qualified Health Centers that established it in partnership with 2 Medicaid managed care plans: Koolauloa Community Health and Wellness Center, Waimanalo Health Center, and Waianae Coast Comprehensive Health Center.
No known activity at this time.
Under the initial solicitation for proposals under the Care Coordination Innovations Project, organizations bidding to become Care Coordination Entities (CCEs) or Managed Care Community Networks (MCCNs) must:
 
  • Be able to facilitate care between hospitals and PCPs, and among hospitals, mental health Providers, substance abuse Providers, and PCPs
  • Demonstrate an adequate medical home network
  • Meet requirements in Section 2703 of the Affordable Care Act (ACA), if the CCE or MCCN plans to implement the Health Homes Option in Section 2703 of the ACA
  • Describe their electronic capabilities and their planned use of health information technology in coordinating care
  • Describe how their care coordination model is sensitive to the culture and specific needs of the populations they propose to serve
No known activity at this time.
A draft accountable care organization (ACO) agreement released by Iowa Medicaid clarified that ACOs must be active Iowa Medicaid providers. They must also be able to demonstrate an integrated delivery system and share clinical information in a timely manner; and implement a model of care and financial management structure that promotes provider accountability, quality improvement, and improved health outcomes.
 
Among other responsibilities for ACOs that wish to participate in the Wellness Plan are that they must:
  • Securely pass clinical information among their patient managers (PMs) to aggregate and analyze data to coordinate care, utilizing both Direct Messaging and query capabilities as available
  • Work with the Department of Human Services to use Iowa Health Information Network capabilities to regularly exchange Admission Discharge Transfer data no later than July 1, 2015
  • Develop relationships with providers that are not ACO PMs and with community resources in its service area, and have a plan for coordinating behavioral health and physical health services and a plan for coordinating and partnering with community-based organizations to further PM outreach capabilities
No known activity at this time.
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State regulations require that a Medicaid-participating entity operating under the coordinated care network shared savings (CCN-S) model be a successful bidder, awarded a contract, and pass a readiness review. A CCN-S must:
 
  • meet the definition of a primary care case manager in accordance with federal regulations;
  • be a legal entity domiciled in Louisiana and registered with the Louisiana Secretary of State’s Office to do business in the state;
  • have the capability to pre-process claims (with the exception of carved-out services) and transfer data to the department’s fiscal intermediary or have a contract with an entity to perform these functions;
  • provide financial reports as requested by the department;
  • post a surety bond for an amount specified by the department for the at-risk portion of the enhanced care management fee;
  • post a performance bond for an amount specified by the department;
  • not have an actual or perceived conflict of interest that, in the discretion of the department, would interfere or give the appearance of possibly interfering with its duties and obligations under this Rule, the contract and any and all appropriate guides
  • and have network capacity to enroll a minimum of 75,000 Medicaid and LaCHIP eligibles into the network in each DHH designated geographic service area.
 

Accountable Communities will be required to serve a minimum number of MaineCare (Medicaid) members (the minimum number has not yet been determined). They must include MaineCare-enrolled providers. Accountable Communities must deliver primary care services and directly deliver or commit to coordinate with specialty providers, including behavioral health for non-integrated practices, and all hospitals in the proposed service area.

 
Accountable Communities will also be required to commit to:
 
 
  • Integration of physical and behavioral health
  • Practice and system transformation
  • Inclusion of patients and families in leadership roles and as partners in care and partners in organizational quality improvement activities
  • Developing formal and informal partnerships with community organizations, social service agencies, local government, etc.
  • Participation in Accountable Community and/or ACO learning collaborative opportunities
 
The Department of Health and Human Services has proposed to align member protection requirements with the Medicare Shared Savings Program. Providers participating in an Accountable Community would be required to:
 
 
  • Post signs indicating participation in Accountable Communities in settings where primary care services are provided, and
  • Make available standardized written notices in plain language developed by the Department of Health and Human Services notifying members of the provider’s participation in Accountable Communities and the potential for MaineCare to share member identifiable data with the Accountable Community
No known activity at this time.
The independent Health Policy Commissioner established by Chapter 224 of the Acts of 2012 is charged with developing certification standards for accountable care organizations (ACOs). While granting the Commission latitude to establish additional standards, the statute establishes twenty criteria for certification, including that certified ACOs must:
 
  • Have functional capabilities to coordinate care financial payments among providers
  • Have significant implementation of interoperable health information technology for the purposes of care delivery coordination and population management
  • Provide medically necessary services across the care continuum including physical and behavioral health services
  • Engage patients in shared decision-making, including on palliative and long-term care services and supports.
 
Provider organizations will use a common application form to apply to become ACOs and can be certified for a renewable term of up to 2 years.
 
The legislation established that the “purpose of the ACO certification process shall be to encourage the adoption of integrated delivery care systems in the Commonwealth for the purpose of cost containment, quality improvement and patient protection.”
The Commissioner is directed to incorporate models and practices that are funded by the state’s Healthcare Payment Reform Fund and found to be successful into the ACO certification standards it develops.
No known activity at this time.
 

Criteria for providers wishing to participate in the demonstration as a health care delivery system (HCDS) were specified in the RFP released by the Department of Human Services. These criteria require participating providers to:

 
 
  • Deliver the full scope of primary care services and either deliver specialty services or demonstrate the ability to coordinate with specialty providers and hospitals
  • Be enrolled as Medicaid providers
  • Demonstrate how the HCDS will affect the total cost of care of its Medicaid participants
  • Incorporate in the care delivery model formal and informal partnerships with community organizations, social service agencies, counties, etc.
  • Engage patients and families as partners in the care they receive
 
A participating HCDS must have a minimum assigned Medicaid population of 1,000 members.
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P.L. 2011, Ch. 114 defines minimum standards for Accountable Care Organization (ACO) demonstration applicants:
  • Applicants must be formed as a nonprofit corporation pursuant to New Jersey state law;
  • Applicants must have a governing board that includes a range of provider, social service, and consumer advocacy representatives (see Governance, above);
  • Applicants must have the support of all general hospitals located in the designated area served by the ACO, no fewer than 75% of the qualified primary care providers located in the designated area, and at least four qualified behavioral health care providers in the designated area;
  • Applicants must have a process for receipt of gainsharing payments from the state and any voluntarily participating Medicaid MCOs;
  • Applicants must have a process for engaging members of the community and for receiving public comments with respect to gainsharing plans;
  • Applicants must have a commitment to become accountable for the health outcomes, quality, cost, and access to care of Medicaid recipients residing in the designated area for a period of at least three years; and
  • Applicants must have a commitment to ensuring the use of electronic prescribing and electronic medical records by health care providers in the designated area.
No known activity at this time.
Accountable care organizations (ACOs) must be issued a certificate of authority by the Commissioner of the Department of Health. The Commissioner is authorized to issue certificates through December 31, 2016. New York’s ACO law NYS Public Health Code Article 29-E specifies a number of areas that will be addressed by the ACO regulations, including:
 
  • Adequacy of an ACO’s network of participating providers, including primary care providers
  • Mechanisms by which an ACO will provide, manage, and coordinate quality health care for its patients, including the potential incorporation of patient-centered medical home standards into the ACO certification process
  • Performance standards, quality measures, and reporting requirements for ACOs
  • Mechanisms that promote evidence-based health  care,  patient  engagement,  coordination  of care, and electronic health records
The law also allows the Department of Health to create an expedited review process for certification of organizations approved by the Centers for Medicare & Medicaid Services to participate in the Medicare Shared Savings Program. These ACOs would be certified as “Medicare-only ACOs.”
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The Oregon Health Authority established certification criteria for Coordinated Care Organizations in March 2012 through administrative rules. Applicants are required to demonstrate capacity for:
 
 
  • Managing financial risk and establishing financial reserves;
  • Meeting minimum financial requirements;
  • Operating within a fixed global budget;
  • Developing and implementing alternative payment methodologies that are based on health care quality and improved health outcomes;
  • Coordinating the delivery of physical health care, mental health and chemical dependency services, oral health care and covered long-term services;
  •  Engaging community members and health care providers in improving the health of the community and addressing regional, cultural, socioeconomic and racial disparities in health care that exist among the entity’s enrollees and the entity’s community
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Health care collaboratives (HCCs) are defined by SB 7 as entities that arrange for medical and health care services for insurers and other payers. They consist of physicians and may include other health care providers and/or insurers.
 
The statute establishes that entities seeking certification as HCCs must demonstrate that they have a sufficient number of primary care physicians in the HCC’s service area, they must show that they have sufficient working capital and reserves to operate the collaborative, and they must pass an antitrust review by the Office of the Attorney General. More details about these requirements were established in regulations proposed by the Texas Department of Insurance in September 2012.
 
Each HCC must also show the “willingness and potential ability” to ensure their approach to service delivery:
  • Increases collaboration among health care providers and integrates health care services
  • Promotes improvement in quality-based health care outcomes, patient safety, patient engagement, and coordination of services, and
  • Reduces the occurrence of potentially preventable events
HCCs must also satisfy the Insurance Commissioner that they have processes in place:

 

  • That contain health care costs without jeopardizing the quality of patient care
  • To develop, compile, and report statistics on performance measures relating to the quality and cost of health care services, the pattern of utilization of services, and the availability and accessibility of services;
  • To address complaints made by patients.
Utah proposes to use Accountable Care Organization (ACO) criteria developed by the National Committee for Quality Assurance (NCQA). Organizations that plan to contract with Utah Medicaid as ACOs will be required to demonstrate that they are seeking NCQA accreditation.
Medicaid-participating providers that form an organization meeting the governance standards may participate in the Medicaid Shared Savings Program. Following the lead of commercial accountable care organization (ACO) pilots in the state, Vermont’s Medicaid Shared Savings Program standards may require ACOs to develop a defined and coordinated strategy for care management.
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