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.
|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) Program: Under the Accountable Care Collaborative (ACC) Program, a total of $20 per-member/per-month (PMPM) is divided among three entities
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.
|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:
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.
|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:
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 Idaho, Pacific Source, and Regence Blue Shield of Idaho. To learn more Idaho Medicaid, see below.
|Illinois||Illinois Health Connect pays primary care providers enhanced fee-for-service rates in addition to the following ongoing care management fees:
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:
Information on specific performance targets is available online.
|Indiana||No known activity at this time.|
|Iowa||IowaCare: The 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:
Further detail on the performance measures is available on pages 42-43 of the IowaCare 1115(a) waiver.
|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:
Both RFPs allow networks to develop performance-based physician incentive plans.
|Maine||Maine PCMH Pilot: For 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
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:
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.
|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):
Payers made several types of payments to support participating medical homes prior to the end of PCMHI in April 2014:
Primary Care Payment Reform Initiative (PCPRI): Participating practices receive three types of payments:
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.
|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:
|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:
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.
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:
Payers may adopt alternative payment methodologies that support the intent of the program subject to the Commissioner of Securities and Insurance’s approval.
|Nebraska||Nebraska Medicaid Patient-Centered Medical Home Pilot: Nebraska 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:
|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 Demonstration: Participating 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 Program: NCQA-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):
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.
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).
|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:
CCNC Networks receive:
Networks return $3.17 and $0.54 monthly for each ABD and non-ABD enrollee to support the central office.
|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 Choice: SoonerCare Choice utilizes multiple payments to incentivize practice transformation. These payments include:
*Providers can use additional codes to bill for enhanced reimbursement when providing care outside of normal business hours.
|Oregon||Oregon Patient-Centered Primary Care Home (PCPCH) Programand ACA Section 2703 Health Homes: Chapter 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:
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:
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:
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:
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.
|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:
Year 1: $0.60
Year 1: $1.50
Year 1: $5.00
Year 1: $7.00
|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:
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.
|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:
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.
|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:
|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: