Project Scope

Project scope refers to a range of model design characteristics, including targeted providers, targeted beneficiary population, scope of services provided, and methodology for assigning beneficiaries to the model.

 

Alabama
Eligible Patient Population: Alabama Medicaid plans to directly contract with regional care organizations (RCOs) for the majority of the Medicaid population (approximately 800,000 beneficiaries). The state would continue and/or expand the existing enhanced primary care case management program (the Patient Care Networks of Alabama program) while the RCOs are under development. Most Medicaid beneficiaries would be included while dual eligibles, those in long term care facilities or utilizing home and community-based waiver services, and the developmentally disabled would be excluded from the initiative.
 
Scope of services: Community-led RCOs would manage and coordinate care for the majority of the non-dually eligible Medicaid population. Through a capitated payment, RCOs would manage the full scope of Medicaid benefits, including physical, behavioral, pharmacy and long-term care services.
 
The state’s 1115 Waiver Concept Paper envisions building the RCOs over time, potentially by phasing them in as pilots across the state. Regions may first opt to develop a PCNA program to serve as the foundation for a future RCO. RCOs would initially manage and be at risk for primary, acute and post-acute care services. As they build capacity, they would be expected to integrate and fully manage behavioral health services for the population served. RCOs will be required to design care coordination programs to ensure these beneficiaries have access to adequate physical and behavioral health care in addition to connecting them with social services.
 
Provider Population A RCO may contract with any willing hospital, doctor or provider to provide services in a Medicaid region if the provider is willing to accept the payments and terms offered to comparable providers. Providers should meet licensing requirements set by law and have a Medicaid provider number. As stated in the initiative’s Planning Principles, any willing provider who chooses to apply does so not only within his or her region, but also across regional lines. Mental health and substance abuse providers currently certified by the Alabama Department of Mental Health (ADMH) and functioning as approved Medicaid providers are expected to be critical participants in RCO and PCNA networks.
 
Federally Qualified Health Centers (FQHCs) are also expected to play a role in the development of both the RCOs and PCNAs as critical primary care providers.
 
Attribution In June 2013, Alabama’s Medicaid agency divided the state into 5 RCO regions. All affected beneficiaries would be required to enroll in an RCO or PCNA based on geographic location.  To the extent there is more than one RCO in a region, beneficiaries would retain the right to choose between RCOs; beneficiaries who do not choose will be auto-assigned. Beneficiaries will also retain their choice of medical provider and medical/health home within network.
Alaska No known activity at this time.
Arizona No known activity at this time.
Arkansas

Provider Population: The Arkansas Health Care Payment Improvement Initiative includes all providers who provide care for Medicaid, Arkansas BlueCross BlueShield, and Arkansas QualChoice; participation is mandatory. Five episodes are initially included in this initiative; providers who do not provide these services or who have limited case-volume are also excluded.

 

Patient Population: Arkansans insured by Arkansas BlueCross BlueShield, Arkansas QualChoice and Medicaid.

 

Scope of Services: The initiative will begin with five episodes of care, though the initiative’s long-term goal for is to have episode-based payment for the majority of episode types within five years. The five initial episodes will be Attention Deficit Hyperactivity Disorder (ADHD), upper respiratory infections, congestive heart failure, hip and knee replacement, and perinatal care. A preparatory phase for these five episodes, which serves as a time for providers to adjust to the new system and for payers to begin collecting preliminary data, launched in July 2012; the performance period began in October 2012.

 

Episodes are defined differently for each episode type (see slide 10):

  • Attention Deficit Hyperactivity Disorder (ADHD): Defined as care over a twelve-month period, and includes all ADHD services and pharmacy costs.
  • Upper respiratory infections: Defined as the care delivered in the 21 days following initial consultation; includes colds, sore throats and sinusitis. Hospital stays and surgical procedures are excluded.
  • Congestive heart failure: Defined as care given from the time of hospital admission for heart failure to 30 days following discharge.
  • Hip and knee replacements: Defined as care delivered from 30 days prior to 90 days after surgery.
  • Perinatal care: Defined as care 40 weeks before to 60 days after delivery; includes prenatal care, delivery, and postnatal maternal care. Excludes neonatal care.

Attribution: Payers use claims data to designate a principal accountable provider (PAP) (a “care quarterback”) for each episode based criteria for each episode type; the PAP can be a provider, a group of providers, or a practice or hospital.  The PAP is identified differently for each episode type; for example, the PAP for a hip or knee replacement (see slide 10) is the orthopedic surgeon. PAPs are responsible for cost and quality of care throughout each care episode, including care provided by other members of the patient’s care team.

California
Scope of services: California Public Employees’ Retirement System (CalPERS) members participating in the accountable care organization (ACO) pilot are receiving a range of health services, which are divided into “cost categories” for the purpose of assigning risk to Blue Shield and the participating providers. The cost categories of financial risk that fell under the pilot’s target cost cap were: facility costs (partner hospital, out-of-area non-partner hospital, and other non-partner hospital), professional costs, mental health costs, pharmacy costs, and ancillary costs.
 

Provider population: The pilot extends only to select practices and hospitals: Hill Physicians in three counties and four Dignity Health hospitals.

 
Eligible patient population: Roughly 41,000 CalPERS members are participating in the ACO pilot, all via their enrollment in Blue Shield NetValue and Access+ HMO health plan in four counties. CalPERS offered a premium discount for selection of the plans participating in the ACO demonstration.
Colorado  

Provider Population: Rollout of the Accountable Care Collaborative (ACC) was phased (see slide 15 in link): in the initial phase, Regional Care Collaborative Organizations (RCCOs) chose communities in which to implement the pilot. During the expansion phase, which began in July 2012, implementation is statewide across the program’s seven regions. Each region has one RCCO. RCCOs are expected to work with patients’ Primary Care Medical Providers to coordinate care, ease care transitions between settings, and connect beneficiaries with specialist services as needed.

 

Patient Population: This program serves Medicaid fee-for-service and Primary Care Physicians Program (a Colorado Medicaid health plan) beneficiaries. Dual eligible and beneficiaries residing in an institutional setting are excluded from the program, as are clients enrolled in Medicaid managed care. The number of children enrolled in the program was initially limited to approximately one-third of the number of total enrollees; the Department plans to remove this limit in October 2012. In addition, beneficiaries are not enrolled if they have a regular provider who is not participating in the ACC program. Enrollment is voluntary and passive for most beneficiaries, though enrollment is mandatory for adult Medicaid beneficiaries without dependent children. In addition to Medicaid beneficiaries, patients with a history of seeing a provider who is participating in the federal Comprehensive Primary Care Initiative will also be enrolled in the ACC program beginning November 1, 2012.

 

As of June 2013, total program enrollment was 352,236, including 222,862 children. Overall, forty-seven percent of Medicaid beneficiaries in the state are enrolled in the program.

 

For more information on enrollment and attribution, refer to the ACC Provider Information page and the ACC Client Selection Fact Sheet.

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
Eligible Patient Population:  The three health centers that comprise the Accountable Healthcare Alliance of Rural Oahu (AHARO) serve a total of approximately 40,000 patients through over 200,000 clinical visits annually. Approximately 50% of these patients (20,000) are enrolled in the Hawaii QUEST (Medicaid) program.
 
QUEST members continuously enrolled in a participating health plan and assigned to a participating health center for at least 3 months are considered to be enrolled in AHARO for the purpose of defining financial performance metrics (see Appendix F).
 
Eligible Provider Population: AHARO is forming partnerships both with a vertical network of providers and with selected Medicaid managed care organizations. Providers are affiliated with the three participating health centers: Koolauloa Community Health and Wellness Center, Waimanalo Health Center, and Waianae Coast Comprehensive Health Center.
No known activity at this time.
Eligible Patient Population: The initial solicitation for provider proposals to form Care Coordination Entities (CCEs) or Managed Care Community Networks (MCCNs) under the Care Coordination Innovations Project identified the eligible patient population as:
  • Seniors,
  • Adults with Disabilities (including long-term care populations, those with Serious Mental illness, Home and Community-based Services Waiver populations, and Dual Eligibles),
  • Other Illinois Health Connect Adults, and
  • Children in the families of adults enrolled in a CCE or MCCN.
Enrollees in a CCE must also be enrolled in Illinois Health Connect, the state’s Medicaid primary care case management program. Medicaid beneficiaries who are enrolled in a managed care organization are not eligible to enroll in a CCE. Initially, the choice to enroll in a CCE or MCCH is voluntary.
 
Provider population: ACEs must include primary care, specialty care, hospitals, and behavioral health providers. CCEs are required, at a minimum, to include primary care providers, hospitals, mental health providers, and substance abuse providers. The matchmaking tool developed by the Illinois Department of Healthcare and Family Services allows community partners interested in forming a CCE to search for a range of potential partners, including general hospital, primary health clinic, public health, home health, hospice, medical equipment, social service/community-based, and dental partners.
 
Primary care physicians may be enrolled in more than one CCE or MCCN.
 
Attribution: Enrollees select an ACE, CCE or MCCN and are locked into their choice for 12 months; they may change CCEs or MCCNs during an annual open enrollment period.
 
Scope of Services: Entities applying to participate in the Care Coordination Innovations Project as an ACE, CCE or MCCN must be able to coordinate care across the spectrum of the health care system with a particular emphasis on managing transitions between levels of care and coordination between physical and mental health and substance abuse.
 
Under Public Act 096-1501, care coordination must include providing or arranging for a majority of care around the patient’s needs, including a medical home with a primary care provider, specialist services, diagnostic and treatment services, mental health and substance abuse services, inpatient and outpatient hospital services, and rehabilitation and long-term care services.
 
The initial solicitation for proposals specifies that MCCNs must, at a minimum, assume risk for services included in Service Package I of the state’s Integrated Care Program: all standard Medicaid medical services, such as physician and specialist care, emergency care, laboratory and X-rays, behavioral health, pharmacy, behavioral health and substance abuse services.
Indiana No known activity at this time.
Scope of Services: The Iowa Wellness Plan members will receive a comprehensive, commercial-like benefit package based on the State Employee Plan benefits, which will ensure coverage for all of the essential health benefits as required by the Affordable Care Act. Iowa will supplement the State Employee Plan services with supplemental dental benefits, similar to those provided in the Medicaid State Plan. Mental health and substance use disorder and dental benefits will be provided on as carved out benefits on a contracted basis.
 
Eligible Provider Population: Iowa’s ACO strategy under its Iowa Wellness Plan is centered on Patient Managers, providers that signed both a Wellness Provider Agreement and a Medicaid Provider Agreement, are part of an ACO, and agree to accept the terms of the agreement with the ACO to serve as a primary care/patient-centered medical home for the member.
 
Eligible Patient Population: The Iowa Wellness Plan is targeted for individuals who are between ages 19 through 64 who do not have access to Medicare or other comprehensive Medicaid coverage, and who are not eligible for cost-effective employer-sponsored coverage. Individuals, who do not have access to cost-effective employer-sponsored coverage, with income up to and including 100 percent of the federal poverty level (FPL) based on the modified adjusted gross income methodology, are considered eligible, and individuals with income up to 133 percent of the FPL who are medically frail will be considered eligible.
 
Attribution: Medicaid beneficiaries enrolled in the Iowa Wellness Plan choose a primary care provider (known as a Patient Manager); the beneficiary is assigned to the ACO if the primary care provider is participating. If a beneficiary does not choose a provider, he is assigned to the provider with whom he had the highest number of unique visits (using evaluation and management codes in the most recent 12 months of claims history).
Kansas No known activity at this time.
Kentucky No known activity at this time.
Patient population: Participation in coordinated care networks in Louisiana is mandatory for categorically needy children up to 19 years of age and their parents; pregnant women; aged, blind, and disabled adults; uninsured women under the age of 65 who have been identified as being in need of treatment for breast and/or cervical cancer; uninsured women eligible through the Louisiana Children’s Health Insurance Program Prenatal Option; and medically needy individuals and families.
 
Participation is voluntary for Native Americans/Alaskan Natives and foster care children.
 
Covered services: A coordinated care network with a shared savings model (CCN-S) provides enhanced primary care case management in addition to contracting with primary care providers for primary care management. The CCN-S is also responsible for coordinating services outside of primary care including, but not limited to:
  • inpatient hospital services;
  • outpatient hospital services;
  • ancillary medical services;
  • organ transplant-related services;
  • EPSDT/Well Child visits;
  • emergency medical services;
  • communicable disease services;
  • emergency medical transportation;
  • home health services;
  • family planning services
  • basic behavioral health services;
  • school-based health clinic services;
  • physician services;
  • maternity services;
  • chiropractic services; and
  • rehabilitation therapy services (physical, occupational, and speech therapies).
Attribution: As part of the eligibility determination process, Medicaid and LaCHIP applicants shall receive information and assistance with making informed choices about the CCNs in their area of residence and the availability of choice counseling. These individuals will have the opportunity to talk with an enrollment broker who shall provide additional information to assist in choosing the appropriate CCN.
 
Each new recipient is given at least 30 calendar days from the postmark date of an enrollment form mailed by the enrollment broker to select a CCN and primary care provider (PCP). Recipients who fail to choose a CCN will be auto-assigned.
 

Eligible Patient Population: All MaineCare members who receive full MaineCare benefits, including Categorically Needy, Medically Needy, SSI-related Coverage Groups, Home and Community-Based Waiver and HIV Waiver members, and others are eligible for attribution to the Accountable Communities.
 
Provider Population: All willing and qualified providers will be eligible to participate in the Accountable Communities initiative. Accountable communities will not be limited by geographic area.
 
Attribution: The Department of Health and Human Services has proposed to align Accountable Communities’ member attribution methodology with that used in the Medicare Pioneer Accountable Care Organization program.
 
Based on historical claims analysis, members will be prospectively assigned to an Accountable Community associated with the primary care practice or specialist where they received a plurality of visits for primary care services (as defined by HCPC codes or revenue codes for Federally Qualified Health Centers). Members who moved or received more than 50 percent of their primary care services in a non-contiguous geographic region to the Accountable Community will be excluded after the performance year.  Members not assigned through a primary care or specialty practice will be assigned to the Accountable Community associated with the hospital where the member receives the majority of their emergency department care. Member freedom of choice will not be restricted.
 
Scope of services A Request for Applications issued by the state in October 2013 lists the defined set of 26 core services that will be factored into the total cost of care calculation for Accountable Communities. These services include primary care case management, behavioral health, inpatient and outpatient services, pharmacy, hospice and home health. Additional optional services—including dental, children’s private non-medical institution, and long term care services—can be included in the Accountable Community’s total cost of care at the Accountable Community’s discretion.
No known activity at this time.

Scope of Services: Accountable care organizations (ACOs) are required by statute to provide medically necessary services across the care continuum, including both physical and behavioral health services. ACOs will need to ensure access to a range of services specified in the legislation, including preventive and primary care services; emergency services; hospitalization services; ambulatory patient services; mental health, substance use disorder and behavioral health services; specialty care; pediatric services; and clinical laboratory and pathology services.

 

Medically necessary services not internally available must be provided to patients outside the ACO. More detailed regulations on the scope of services offered by ACOs are forthcoming.

 

Eligible Provider Population: Provider organizations that meet the criteria for participation set in the statute (and supplemented by forthcoming regulations) may apply to become an ACO. The legislation specifies that provider organizations include any corporation, partnership, business trust, association or organized group of persons, that is in the business of health care delivery or management and represents one or more health care providers in contracting with insurers for the payments of heath care services. This includes physician organizations, physician-hospital organizations, independent practice associations, and other provider networks.

 

Eligible Patient Population: Participating patient populations are not addressed in the legislation.

 

Attribution: Attribution of patients to ACOs is not described in the legislation.

No known activity at this time.
 

Eligible patient population: Most Medicaid enrollees in the state are eligible to participate in the demonstration if they are attributed to a participating provider. Exceptions are noted in the Request for Proposals (RFP) released by the Department of Human Services (DHS) and include blind or disabled Medicaid beneficiaries who are dually eligible for Medicare and beneficiaries receiving Medicaid benefits on a medical spend down basis.

 

Provider population: Providers who apply to participate in the demonstration must be enrolled Medicaid providers meeting criteria established in the RFP. Participating health care delivery systems (HCDSs) need not compel all of their providers to participate, particularly when the HCDS uses different care models in different locations around the state; the scope of the demonstration may be limited to sub-segments of clinics and systems that have specific models of care in some locations but not others.

 

 

Attribution: The RFP for the demonstration specifies that a preliminary population will be determined for each HCDS at the beginning of the performance period. At the end of the performance period, the attribution population will be re-calculated for accountability purposes. Attribution will be determined using a hierarchical process (based first on participant enrollment in a certified Health Care Home) described in the RFP. Answers from the DHS to questions submitted on the RFP establish that a minimum threshold of enrollment will be set for inclusion in the attribution model and there will not be geographic limits on enrollee attribution.

 

 

Scope of Services: Health care delivery systems (HCDSs) participating in the demonstration will be responsible for the total cost of care of their Medicaid patient populations participating in the demonstration. A DHS memorandum on definitions of total cost of care identified criteria for the inclusion of services in the definition of total cost of care:

 

 

  • Services provided by the primary care entities and other providers within the HCDS demonstration;
  • Services ordered by the primary care entities and other providers within the HCDS demonstration (e.g. laboratory services, consultations, therapies, hospitalizations , etc.);
  • Services whose utilization would reasonably and significantly be affected by the coordination of care envisioned by this demonstration; and
  • Services that may have otherwise been included by the criteria listed above, but whose provision would provide value primarily beyond of the calculation of total cost of care have been excluded (e.g. respite care and long term acute hospital).

 

Specific procedure/revenue codes for included services were provided in a table released by the DHS.

 

Under the Minnesota Accountable Health Model, the state’s federally funded State Innovation Model to expand upon the HCDS Demonstration, the state will expand the scope of services to include mental health and long-term supports and services.

Mississippi No known activity at this time.
No known activity at this time.
Montana No known activity at this time.
No known activity at this time.
Nevada No known activity at this time.
New Hampshire No known activity at this time.
 

Patient Population: Each organization applying for certification as an Accountable Care Organization (ACO) must cover “a municipality or defined geographic area in which no fewer than 5,000 Medicaid recipients reside.” All Medicaid beneficiaries within an ACO’s defined geographic range are eligible to receive services from the ACO, though Medicaid beneficiaries may seek care outside of the ACO.

 

Scope of Services: P.L. 2011, Ch. 114 does not identify a scope of services that ACOs must include. However, the state’s approved 1115 waiver request to CMS specifies that ACOs will provide access to all services available under the State Plan. ACOs are expected to be integrated into their communities so that they can assist in coordinating community-based services for enrollees. Regulations issued in 2013 specify that the demonstration’s objectives include increasing access to primary care, behavioral health care, pharmaceuticals and dental care.

Provider population: ACOs are required to obtain the support of all general hospitals in the designated area, at least 75 percent of the primary care providers in the designated area, and at least four qualified behavioral health providers in the designated area (including at least one Department of Human Services-licensed mental health program and one Department-licensed substance abuse program).

 

 

No known activity at this time.
Scope of Services: The statute does not specifically define the “array of services” that accountable care organizations (ACOs) will deliver. However, the statute is clear that primary care will be a critical component of the services offered by ACOs.
 
Patient Population: A definition of the population proposed to be served by an ACO, which may includes references to geographic area and patient characteristics, will be promulgated by the New York Department of Health in forthcoming regulations.
 
New York’s ACO law, NYS Public Health Code Article 29-E, calls for the convening of a workgroup by the Department of Health that will develop a proposal whereby an ACO—instead of a managed care plan—may serve Medicaid or Family Health plus enrollees who are required to participate in managed care.

 

Provider Population: The law does not limit which licensed health care providers may apply for certification as an ACO. It does, however, establish that ACOs shall use their best efforts to include any willing Federally Qualified Health Centers (FQHCs) among their participants, provided the FQHCs serve the area and population served by the ACO.

No known activity at this time.
North Dakota No known activity at this time.
Ohio No known activity at this time.
No known activity at this time.
 

Population: Nearly all Oregon Health Plan enrollees, including Medicaid beneficiaries who are dually eligible for Medicare will be enrolled in Coordinated Care Organizations (CCO)s. The only Oregon Health Plan enrollees not subject to mandatory enrollment requirements are: noncitizens, American Indians/Alaska Natives, dual eligibles enrolled in a PACE program, enrollees who receive an exemption, and individuals who reside in an area not served by a CCO.

 

Under the State Innovation Model grant received by Oregon in early 2013, the model will be expanded beyond the Oregon Health Plan to public employees covered through the Public Employees Benefit Board, Medicare for dual eligibles, and commercial payers.

Scope of services: CCOs are responsible for integrating and coordinating physical, mental, behavioral and dental health care for enrollees. Oregon Department of Human Services Medicaid-funded long-term care services will not be provided by CCOs.

 

Attribution: Administrative rules governing the project stipulate that Oregon Health Plan beneficiaries choose the Coordinated Care Organization into which they would like to enroll. Beneficiaries that fail to choose a CCO will be assigned to a CCO that is open for enrollment, services the county in which the beneficiary resides, and has practitioners located within the community-standard distance for average travel time for the beneficiary.

No known activity at this time.
No known activity at this time.
South Carolina No known activity at this time.
South Dakota No known activity at this time.
Tennessee No known activity at this time.
Texas
Scope of services: The health care services for which health care collaboratives (HCCs) have responsibility is defined broadly in SB 7 as “services provided by a physician or health care provider to prevent, alleviate, cure, or heal human illness or injury.” The legislation explicitly notes that this includes pharmaceutical, medical, chiropractic, dental, and hospital care.
 
Eligible provider population: The statute does not place restrictions on physicians and health care providers licensed in the state of Texas from voluntarily joining HCCs. It does specify that an HCC may not prohibit a physician or other provider, as a condition of participating in that HCC, from participating in another HCC.
 
Aside from broad requirements for certification by the Texas Department of Insurance (described in the “Criteria for Participation” section), many of the details of HCC arrangements, including attribution and eligible patient populations, will be determined in contracts between HCCs and interested public and private payers. SB 7 provides the legal framework by which physicians and other providers can form new entities—specified in the legislation as having “all powers of a partnership, association, corporation, or limited liability company”—that can pursue more integrated delivery models and potentially assume more accountability for patient populations.
Scope of Services: Utah’s Accountable Care Organization (ACO) contracts would include inpatient hospital, outpatient hospital, physician services and other ancillary services, as well as pharmacy benefits. ACOs would not be responsible for mental health services, substance abuse treatment services, nursing facilities, or transportation.
 
Eligible Patient Population: All Medicaid beneficiaries are eligible for the ACOs, except for those in a nursing or inpatient facility.
 
Enrollment: Reflecting the program’s roots in managed care, Medicaid enrollees will choose an ACO contractor who will be responsible for the costs and quality of the care provided to them. Utah currently has mandatory enrollment in managed care plans in its four most populous counties, and the state proposes to implement the ACO contract model in those same four counties. Those who do not choose will be assigned and attributed to an ACO.
Patient population: All Medicaid beneficiaries that fall into one of the following “super eligibility categories” are eligible for assignment to a Medicaid accountable care organization (ACO) under the Medicaid Shared Savings Program: aged, blind or disabled adults who are not eligible for Medicare; blind or disabled children who are not eligible for Medicare; general adult; new adult; general child; and SCHIP child.
 
Attribution: Claims for specified CPT codes are analyzed for Medicaid beneficiaries falling into one of the super eligibility categories identified above who were enrolled for the entire 12 month look back period (the most recent 12 months for which claims are available). Beneficiaries are assigned to the practice where he or she had the greatest number of qualifying claims. Beneficiaries without claims experience are assigned to the primary care provider they have selected or to whom they have been auto-assigned.
 
Covered services: Medicaid ACOs will be responsible for Medicaid-covered services. Unlike ACOs supported by other payers, Medicaid ACOs will be responsible for spending on prescription medications; dental benefits; transportation; waiver services; mental health and substance abuse services; and services administered through the state’s Department of Education.
Virginia No known activity at this time.
No known activity at this time.
No known activity at this time.
Wisconsin No known activity at this time.
Wyoming No known activity at this time.
 

 

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