Frequently Asked Questions from Primary Care Providers
Maryland’s Multi-payer Patient Centered Medical Home Program (MMPP), coordinated by the Maryland Health Care Commission (MHCC), is now underway. While not all of the Program details are finalized, the basic outline of the program is in place. Listed below are some frequently asked questions that MHCC has received and answered. This list will be updated regularly.
Carrier and Payer Participation
1. What carriers will be participating in Maryland’s Multi-payer Patient Centered Medical Home Program (MMPP)?
Aetna, CareFirst BlueCross BlueShield, CIGNA, United Healthcare, and Coventry are required to participate under the law establishing the MMPP.
2. Will Medicaid and/or Medicaid Managed Care Organizations (MCOs) participate in Maryland’s Multi-payer PCMH Program?
Yes, the Medicaid MCOs will participate.
3. Will the Program include Medicare?
The Centers for Medicare and Medicaid Services (CMS) has announced a six state Multi-payer Advanced Primary Care Practice Demonstration project to allow Medicare to participate in state-sponsored PCMH Programs. Maryland has submitted an application and we expect CMS to announce awards by late fall 2010.
1. What are the selection criteria for providers?
Maryland’s Multi-payer Patient Centered Medical Home Program has accepted applications from primary care providers – family practice, internal medicine, geriatric and pediatric physicians, and nurse practitioners – throughout the State. The Program aims to select a wide-range of practices. The selection criteria will include geographic diversity, as well as, practice size and type of ownership, such as physician-owned, hospital-owned, part of a faculty practice organization, and Federally Qualified Health Centers (FQHCs).
2. Since nurse practitioner-led practices are not recognized by NCQA and NCQA recognition is required, can they participate?
NCQA has agreed to review nurse practitioner-led practice applications and forward the details of those evaluations to MHCC. MHCC will recognize the practices that meet the Level 1+ and Level 2+ requirements for purposes of the Program. These practices will not be recognized on the NCQA website.
3. Do all providers in a multi-site practice have to participate in the MMPP?
If a practice has multipIf a practice has multiple sites, it will designate the sites that will participate. All providers at a selected-practice site will need to participate in the Program. Maryland’s Multi-payer PCMH Program requires practice sites to submit an application for NCQA PPC-PCMH recognition within about 6 months from the start of the program. PPC-PCMH recognition is site specific and assumes that all providers working at the site participate. Designating specific sites may be an effective strategy as it is unlikely that all practice sites could be selected to participate.
4. Can a practice participate in the Maryland Multi-payer PCMH Program (MMPP) and a single payer PCMH program such as the CareFirst program?
Practice selection for the MMPP program is site specific, consistent with NCQA Recognition requirements. CareFirst is enrolling practices on an organization-wide basis. A practice location selected to participate in the MMPP that is also in a practice that joins the CareFirst program may participate in both Programs according to the following conventions:
- The MMPP patient participation rules, payment methodologies and quality reporting requirements will govern the practice location that participates in both programs.
- CareFirst, at its own discretion, may supplement the MMPP payment methodology consistent with its own program for that practice locations in both locations.
- Other practice locations that are not in the MMPP will be governed solely by the CareFirst program rules.
5. Does a practice have to be in-network with all commercial carriers to participate in the Program?
No, a practice does not have to be in-network with all carriers. A practice can only receive additional payments from those carriers with which it has a contract. If the practice is not in-network with at least 2 of the 5 commercial carriers mandated to participate in this program, it may not be cost effective for the practice to participate in the MMPP.
1. How will participating Program providers inform their patients about the program?
MHCC will work with participating providers to design outreach materials for engaging patients in the MMPP. Providers will be responsible for ensuring that basic information regarding the Program reaches all patients in the practice’s panel. The letter to patients will inform them of their right to opt-out of Maryland’s PCMH Program. Patients who choose not to be counted in the Program will continue to receive the same quality of care that they had received previously. The practice will not receive a per patient per month (PPPM) reimbursement for those patients who opt-out, and they will not be included in quality measurement.
2. If a patient opts out, will s/he be able to opt-in at a later date?
Yes, every six months patient attribution will be refreshed to account for patients joining and leaving the practice.
3. How will patients be attributed to a MMPP practice?
At this time, we anticipate that each practice will provide a list of its patients and the patients’ insurers to MHCC. These lists will be matched against carrier enrollment records and claims histories. A patient will be assigned to the practice where s/he receives the most primary care services. Primary care services will be calculated using the E&M encounters for the previous two years. If no medical claims are present, then the patient will be linked through pharmacy claims, if possible. A process will be worked out to attribute patients that have changed carriers in the previous two years, but have remained with the same practice.
4. If a practice has multiple locations, how will patients at the various practice locations be included in the Program?
In Maryland’s PCMH Program, each practice location, whether or not it is part of a larger group practice, will have to apply to participate. This reflects the NCQA’s PPC-PCMH Recognition standards which allocate recognition by practice location. Patients at a selected practice location will be eligible to participate in the Program.
Provider Payment and Incentives
1. Is Maryland’s PCMH Program payment structure different from a managed care capitation payment?
Yes, Maryland’s PCMH Program is designed to offer providers a fixed and incentive payment in addition to the fee-for-service payment they receive for treating patients. Neither the fixed nor the incentive payments are global capitation payment for all patient treatment services.
2. What type of payment can I expect as a PCMH Program practice?
In addition to the regular fee-for-service payments, there are two types of enhanced reimbursement. Practices will receive a per patient per month (PPPM) payment for attributed patients. This fixed payment will offset expenses associated with providing PCMH services. The payment will be paid in semi-annually. Payments will be adjusted by the number of patients in a practice, payer category (commercial, Medicaid, Medicare) and NCQA Level of recognition. Practices will also be eligible to share in cost savings from reductions in emergency department and hospital utilization each year.
3. When will a Program practice be eligible to receive the fixed PPPM payments?
It is understood that there are upfront expenses associated with becoming a medical home and practices will require investment to begin operating as medical homes. Practices will become eligible to receive fixed payments starting April 1, 2011.
4. How will fixed and incentive payments be made?
Fixed payments will be made to practices directly from carriers semiannually. Incentive payments will be calculated and made retrospectively. Practices will have to meet a threshold of quality measures before they will be eligible to receive incentive payments. Practices will be responsible for disbursing the fixed and incentive payments among the providers at their participating practice location.
5. Can a practice receive a subsidy from a private carrier for Electronic Health Record (EHR) implementation as defined in House Bill 706 (Act of 2009) and also participate in the Maryland Multi-Payer PCMH Program?
A primary care practice can participate in the Maryland Multi-payer PCMH Program and State Electronic Health Record (EHR) Subsidy Program, however any EHR subsidies will be included in countable costs for the PCMH shared savings computation. For example, if a practice location receives $15,000 in EHR subsidies in 2011, those payments will be counted as expense to the practice when the shared savings are calculated. The treatment of EHR subsidy payments is identical to how the PCMH Fixed Payments are considered in the share savings computation.
6. Can one of the major commercial carriers (Aetna, CIGNA, CareFirst, Coventry, United HealthCare) receive a waiver from participating in the Maryland Multi-Payer PCMH Program?
No, the legislation establishing the MMPP requires any commercial carrier with premium revenue in the State of $90 million or more to participate in the Program. MHCC has determined that Aetna, CareFirst, CIGNA, Coventry, and United HealthCare must participate in the MMPP because each carrier had health care premiums revenue above $90 million, no waivers have been requested and none are planned.
1. What does NCQA Level 1+ and Level 2+ mean?
Maryland is considering designating “must pass” elements within each of the nine NCQA domains. These elements have been more strongly linked to potential reductions in costs to the purchasers and patients and, as such, are a priority.
2. Will practices be required to pay the NCQA application fee?
The Maryland Health Care Commission is working to obtain external funding to cover practices’ NCQA application fees. At this time, the Commission has not identified a funding source, but will notify Program practices when and if funding becomes available. Fees for first-time applications include a standard $80 for the survey tool license and $450 per physician. If a practice has six or more physicians, the fee is $2,700 for all physicians practicing at the site applying for recognition.
3. Will practices be required to have an operating Electronic Health Record to participate in the Program?
No, practices will not be required to have an operating EHR to participate in the Program initially. The Program will require practices to have a registry, either as part of an Electronic Health Record, or as a stand-alone program, to meet NCQA Level 1+ recognition. However, to achieve Level 2+, an EHR with decision support is required. Practices need to reach Level 2+ within 18 months of becoming a Program practice.
4. Will practices be required to have NCQA PPC-PCMH Recognition prior to applying for the Program?
No, the Program requires that practices to apply for NCQA Level 1+ or higher recognition within 6 months of the commencement of the Program on January 4, 2011. Practices must achieve NCQA Level +1 or higher recognition by December 2011 and NCQA Level 2+ or higher recognition within 18 months of the Program commencement.
1. Will practices be responsible for reporting quality measures during the Program?
Yes, practices will be responsible for collecting information on their performance as part of NCQA recognition. Practices will be asked to report process measures for at least one of the following conditions: diabetes, heart/stroke management, and asthma control. Reporting requirements will be aligned with Medicare and Medicaid’s electronic health records meaningful use definition for bonus payments and with Medicare’s PQRI standards, if possible.
2. Will quality measurement affect Program practices’ incentive payments?
Practices earn incentive payments based on meeting quality targets. Practices will also have to meet certain utilization reduction thresholds in order to receive relevant incentive payments from meeting quality targets.
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