Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.15-017 - PCMH 1-15; DMS 801,844, 845, & 846; SecV 8-15

Current through Register Vol. 49, No. 6, June, 2024
200.000
DEFINITIONS
Attributed beneficiaries
The Medicaid beneficiaries for whom primary care
						  physicians and participating practices have accountability under the PCMH
						  program. A primary care physician's attributed beneficiaries are determined by
						  the ConnectCare Primary Care Case Management (PCCM) program. Attributed
						  beneficiaries do not include dual eligible beneficiaries.
Attribution
The methodology by which Medicaid determines
						  beneficiaries for whom a participating practice may receive practice support
						  and shared savings incentive payments.
Benchmark cost
The projected cost of care for a specific shared
						  savings entity against which savings are measured. Benchmark costs are
						  expressed as an average amount per beneficiary.
Benchmark trend
The fixed percentage growth applied to PCMH practices'
						  historical baseline fixed costs of care to project benchmark cost.
Care coordination
The ongoing work of engaging beneficiaries and
						  organizing their care needs across providers and care settings.
Care coordination payment
Quarterly payments made to participating practices to
						  support care coordination services. Payment amount is calculated per attributed
						  beneficiary, per month.
Cost thresholds
Cost thresholds are the per beneficiary cost of care
						  values (high and medium) against which a shared savings entity's per
						  beneficiary cost is measured.
Default pool
A pool of beneficiaries who are attributed to
						  participating practices that do not meet the requirements in Section 233.000,
						  part A or part B.
Historical baseline cost of care
A multi-year weighted average of a shared savings
						  entity's per beneficiary cost of care.
Medical neighborhood barriers
Obstacles to the delivery of coordinated care that
						  exist in areas of the health system external to PCMH.
Minimum savings rate
A fixed percentage set by DMS. In order to receive
						  shared savings incentive payments for performance improvement described in
						  Section 237.000, part A, a shared savings entity must achieve a per beneficiary
						  cost of care that is below its benchmark cost by at least the minimum savings
						  rate.
Participating practice
A physician practice that is enrolled in the PCMH
						  program, which must be one of the following:
A. An individual primary care physician (Provider Type
						  01 or 03);
B. A physician group of primary care providers
						  who
are affiliated, with a common group identification
						  number (Provider Type 02, 04 or 81);
C. A Rural Health Clinic (Provider Type 29) as defined
						  in the Rural Health Clinic Provider Manual Section 201.000; or
D. An Area Health Education Center (Provider type
						  69).
Patient-Centered Medical Home (PCMH)
A team-based care delivery model led by Primary Care
						  Physicians (PCPs) who comprehensively manage beneficiaries' health needs with
						  an emphasis on health care value.
Per beneficiary cost of care
The risk- and time-adjusted average of attributed
						  beneficiaries' total Medicaid fee-for-service claims (based on the published
						  reimbursement methodology) during the performance period, net of
						  exclusions.
Per beneficiary cost of care floor
The lowest per beneficiary cost of care for which
						  practices within a shared savings entity can receive shared savings incentive
						  payments.
Per beneficiary savings
The difference between a shared savings entity's
						  benchmark cost and its per beneficiary cost of care in a given performance
						  period.
Performance period
The period of time over which performance is aggregated
						  and assessed.
Pool
A. The beneficiaries who are attributed to one or more
						  participating practice(s) for the purpose of forming a shared savings entity;
						  or
B. The action of aggregating beneficiaries for the
						  purposes of shared savings incentive payment calculations (i.e., the action of
						  forming a shared savings entity).
Practice support
Support provided by Medicaid in the form of care
						  coordination payments to a participating practice and practice transformation
						  support provided by a DMS contracted vendor.
Practice transformation
The adoption, implementation and maintenance of
						  approaches, activities, capabilities and tools that enable a participating
						  practice to serve as a PCMH.
Primary Care Physician (PCP)
See Section 171.000 of the Arkansas Medicaid provider
						  manual.
Provider portal
The website that participating practices use for
						  purposes of enrollment, reporting to the Division of Medical Services (DMS) and
						  receiving information from DMS.
Recover
To deduct an amount from a participating practice's
						  future Medicaid receivables, including without limitation, PCMH payments, or
						  fee-for-service reimbursements, to recoup such amount through legal process, or
						  both.
Remediation time
The period during which participating practices that
						  fail to meet deadlines, targets or both on relevant activities and
metrics tracked for practice support may continue to
						  receive care coordination payments while improving performance.
Risk adjustment
An adjustment to the cost of beneficiary care to
						  account for patient risk.
Same-day appointment request
A beneficiary request to be seen by a clinician within
						  24 hours.
Shared savings entity
A PCMH or pooled PCMHs that, contingent on performance,
						  may receive shared savings incentive payments.
Shared savings incentive payment cap
The maximum shared savings incentive payment that DMS
						  will pay to a shared savings entity, expressed as a percentage of that entity's
						  benchmark cost for the performance period.
Shared savings incentive payments
Annual payments made to reward cost-efficient and
						  quality care.
Shared savings percentage
The percentage of a shared savings entity's total
						  savings that is paid to the PCMH in a shared savings entity.
State Health Alliance for Records Exchange
						  (SHARE)
The Arkansas Health Information Exchange. For more
						  information, qo to http://ohit.arkansas.aov
.
211.000
Enrollment Eligibility
To be eligible to enroll in the PCMH program:
A. The entity must be a participating
			 practice as defined in Section 200.000.
B. The practice must include PCPs enrolled in
			 the ConnectCare Primary Care Case Management (PCCM) Program.
C. The practice may not participate in the
			 PCCM shared savings pilot established under Act 1453 of 2013.
D. The practice must have at least 300
			 attributed beneficiaries at the time of enrollment.
DMS may modify the number of attributed beneficiaries required
				for enrollment based on provider experience and will publish at
www.pavmentinitiative.org
any
				such modification.
E. The
			 practice must meet eligibility criteria as specified in the conditions for
			 enrollment as indicated in the PCMH activities and metrics list. These criteria
			 are published at
www.pavmentinitiative.org/referenceMaterials/Documents/2016PCMHProgramPolicv
Addendum.pdf
.