Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.18-017 - Amendment to Medicaid Patient-Centered Medical Home PCMH

Current through Register Vol. 49, No. 6, June, 2024
Section II Patient-Centered Medical Home
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 incentive payments.
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.
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.
Medical neighborhood barriers
Obstacles to the delivery of coordinated care that
						  exist in areas of the health system external to PCMH.
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.
Performance-based incentive payments
Performance-based incentive payments are payments made
						  to a shared performance entity for delivery of economic, efficient and quality
						  care
Performance adjustment
An adjustment to the cost of beneficiary care to
						  account for patient risk.
Performance period
The period of time over which performance is aggregated
						  and assessed.
Petite pool
Pool reserved for practices with less than 300
						  attributed beneficiaries that do not wish to participate in a voluntary
						  pool.
Pool
A. The beneficiaries who are attributed to one or more
						  participating practice(s) for the purpose of forming a shared performance
						  entity; or
B. The action of aggregating beneficiaries for the
						  purposes of performance-based incentive payment calculations (i.e., the action
						  of forming a shared performance entity).
Practice support
Support provided by Medicaid in the form of care
						  coordination payments to a participating practice .
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.
Quality Improvement Plan (QIP)
QIP is a plan of improvement that practices must submit
						  to PCMH Quality Assurance team after receiving notice of attestation failure or
						  validation failure.
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.
Same-day appointment request
A beneficiary request to be seen by a clinician within
						  24 hours.
Shared performance entity
A PCMH or pooled PCMHs that, contingent on performance,
						  may receive performance-based incentive payments.
State Health Alliance for Records Exchange
						  (SHARE)
The Arkansas Health Information Exchange. For more
						  information, qo to http://ohit.arkansas.qov
.
213.000
Enrollment Schedule
Enrollment is open for approximately six (6) weeks in Quarter 3
				and Quarter 4 of the preceding calendar year.
DMS will not accept any enrollment documents received other
				than during an enrollment period.
221.000
Practice Support Scope
Pooling is effective for a single performance period and must
				be renewed for each subsequent year.
When a PCMH has voluntarily pooled, its performance is measured
				in the associated shared performance entity throughout the duration of the
				performance period unless it withdraws from the PCMH program during the
				performance period. When a PCMH in a voluntary pool withdraws, is suspended, or
				otherwise leaves the PCMH program, any and all PCMHs in the shared performance
				entity will have their performance measured as if the withdrawn or suspended
				PCMH had never participated in the pool. This provision does not apply to PCMHs
				that leave the program in the last calendar quarter. If the PCMH leaves the
				program in the last calendar quarter, the departing PCMH, and its performance
				will be treated as if the PCMH has not left the program.
235.000
Performance-Based Incentive
			 Payment (PBIP) Methodology
Each year, a Practice's performance in emergency department
				rates and inpatient rates will be measured and ranked. Shared performance
				entities that achieve the top 35th percentile of
				performance in the measures will be eligible to receive PBIP.
Certain conditions are excluded from the calculation of
				emergency room and inpatient rates. Each year, DMS will announce which
				exclusions it has applied on the API I website at
http://www.paymentinitiative.org/pcmh-manual-and-additional-resources
.
236.000
Focus Measure
Each year, DMS will select a focus measure to improve quality
				and provide incentive to shared performance entities. The focus measure will
				focus on an area for which Arkansas ranks much lower than the national average.
				Shared performance entities that are ranked in the top 35th
				  percentile of the focus measure will be eligible to receive
				PBIP.
Each year, DMS will announce which area has been selected as a
				focus measure on the API I website at
http://www.pavmentinitiative.org/pcmh-manual-and-additional-resources
.
Each year, DMS will announce which area has been selected as a
				focus measure on the API I website at
http://www.pavmentinitiative.org/pcmh-manual-and-additional-resources
.
237.000
Performance-Based Incentive
			 Payment Amounts
A shared performance entity is eligible to receive
				performance-based incentive payments in one of the following ways:
A. Shared performance entities that are
			 ranked on the top 10th percentile of performance in
			 emergency room rates, inpatient stay rates, and focus measures will be eligible
			 for 100% of incentive bonus.
B.
			 Shared performance entitles that rank in the top 35th percentile of performance
			 in emergency room rates, inpatient stay rates, and focus measures will be
			 eligible for 50% of incentive bonus.
Performance-based incentive payments will be calculated by
				multiplying the incentive amount by the number of member months attributed to
				each PCMH. PCMHs are eligible to receive incentive payments for either ranking
				in the top 10th or top 35th percentile for each measure. Measures are
				independent of one another, and practices are not required to achieve the same
				ranking across all measures to qualify for incentive bonus payments.
If participating practices have pooled their attributed
				beneficiaries together, then performance-based incentive payments will be
				allocated to those practices based on risk-and time-adjustment and in
				proportion to the number of attributed beneficiaries that each PCMH contributed
				to such pool.
1. A shared performance
			 entity will not receive performance-based incentive payments unless it meets
			 all the conditions described in Section 232.000.
Practice support is care coordination payments made to a PCMH
				to support the practices' transformations.
Receipt and use of the care coordination payments is not
				conditioned on the PCMH engaging a care coordination vendor, as payment can be
				used to support participating practices' investments (e.g., time and energy) in
				enacting changes to achieve PCMH goals. Care coordination payments are
				risk-adjusted to account for the varying levels of care coordination services
				needed for beneficiaries with different risk profiles.
DMS may pay, recover or offset overpayment or underpayment of
				care coordination payments.
DMS will also support PCMHs through improved access to
				information through the reports described in Section 244.000.
222.000
Practice
			 Support Eligibility
In addition to the enrollment eligibility requirements listed
				in Section 211.000, in order for PCMHs to receive practice support, DMS
				measures PCMH performance against activities tracked for practice support
				identified in Section 241.000. PCMHs must meet the requirements of this section
				to receive practice support.
Each PCMH in a shared performance entity will, if individually
				qualified, receive practice support even if another PCMH in a shared
				performance entity does not qualify for practice support.