5160-1-72 Patient centered medical homes (PCMH): payments.

 

 

 

5160-1-72                    Patient centered medical homes (PCMH): Payments.

 

 

 

(A)A Patient centered medical home (PCMH) must be enrolled and meet the requirements set forth in rule 5160-1-71 of the Administrative Code to be eligible for PCMH payments.

 

(B)An eligible PCMH may qualify to access the following payments:

 

(1)The "PCMH per-member-per-month (PMPM)" is a payment to support the PCMH.

 

(a) Payment is in the form of a prospective risk-adjusted PMPM payment that will be calculated for each attributed medicaid individual using 3M clinical risk grouping (CRG) software to categorize the individual into one of the following risk tiers:

 

(i) Healthy individuals including those with a history of significant acute diseases or a single minor chronic disease;

 

(ii) Individual with minor chronic diseases in multiple organ systems, significant chronic disease, or significant chronic diseases in multiple organ systems;

 

(iii) Individual with dominant chronic diseases in three or more organ systems, metastatic malignancy, or catastrophic condition.

 

(b) Payment begins following enrollment and in accordance with the payment schedule published on the ODM website, www.medicaid.ohio.gov;

 

(2)The "PCMH shared savings payment" is a payment for a PCMH that meets quality and financial outcomes. Specific information regarding the PCMH shared savings payment can be found on the ODM website, www.medicaid.ohio.gov.

 

(a) To be eligible for the PCMH shared savings payment, the PCMH must meet the following requirements:

 

(i) The PCMH must have at least sixty thousand member months in the performance period;

 

(ii) The PCMH must achieve savings on its total cost of care during the performance period compared to its own baseline total cost of care performance, and/or perform in the top decile of all PCMH practices based on total cost of care performance. The total cost of care for a PCMH is calculated by summing all claims for a given patient, plus any PMPM payment that the PCMH has received through the PCMH program, minus several exclusions and taking into  account  the  overall  risk  status  of  the  population.  The

 

 

following categories of expenditures are excluded:

(a) All expenditures for waiver services;

(b) All   expenditures   for   dental,   vision,   and   transportation services;

(c) All expenditures in the first year of life for members with a neonatal intensive care unit (NICU) level three or four stay;

(d)All expenditures for outliers within each risk band in the top and bottom one percent; and

(e) All expenditures for individuals with more than a specified number of consecutive days in a long-term care facility.

(b) The PCMH shared savings payment consists of the following:

(i) An annual retrospective payment equivalent to a percentage of the savings on total cost of care over the course of the performance period. The percentage will be determined by several factors including but not limited to the PCMH's total cost of care for its attributed medicaid individuals as defined in (B)(1) of Administrative Code rule 5160-1-71; and

(ii) An annual retrospective bonus payment based on total cost of care for PCMHs in the top-performing decile, to be determined annually by ODM.

(C)Penalties.

(1) The PCMH must continue to meet activity requirements annually as defined in paragraph (G) of Administrative Code rule 5160-1-71. If activity requirements are not met upon evaluation, payment under this  rule terminates; and

(2) The PCMH must continue to meet efficiency and clinical quality requirements defined in paragraphs (H) and (I) of Administrative Code rule 5160-1-71. If any of these requirements are not met, a warning will be issued. After two consecutive warnings, payment under this rule will be terminated.

(D) A PCMH may utilize reconsideration rights as stated in 5160-70-01 and 5160-70-02 of the Administrative Code to challenge decisions by ODM to terminate payments described in this rule.

Effective:		10/01/2016
Five Year Review (FYR) Dates:		10/01/2021
CERTIFIED ELECTRONICALLY
Certification
09/20/2016
Date
Promulgated Under:	119.03
Statutory Authority:	5164.02
Rule Amplifies:	5164.02