Ohio Admin. Code 5160-19-02 - Patient centered medical homes (PCMH): payments

(A) A patient centered medical home (PCMH) has to be enrolled and meet the provisions set forth in rule 5160-19-01 of the Administrative Code to be eligible for PCMH payments.

(B) A PCMH participating in the PCMH for kids program has to be enrolled as a PCMH and meet all provisions set forth in rule 5160-19-01 of the Administrative Code to be eligible for PCMH for kids payments.

(C) An eligible PCMH may qualify for 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 is calculated for each attributed medicaid individual by 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 determined by ODM;

(2) The "PCMH for kids enhanced per-member-per-month (PMPM)" is a payment to support the PCMHs participating in the PCMH for kids program.

(a) Payment is in the form of a prospective flat PMPM payment per attributed medicaid pediatric individual;

(b) Payment begins following PCMH enrollment in PCMH for kids and in accordance with the payment schedule determined by ODM.

(3) The "PCMH shared savings payment" is a payment for a PCMH that meets quality, efficiency, and financial outcomes. PCMH practices are not eligible to earn this payment for the 2020 calendar year as they are not subject to the quality and efficiency metric thresholds.

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

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

(ii) The PCMH can achieve savings on its total cost of care during the performance period compared to its own baseline total cost of care performance, or by performing 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 the following 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 attributed medicaid individuals 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 per cent; and

(e) All expenditures for individuals with more than ninety 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 the PCMH's total cost of care for its attributed medicaid individuals as defined in paragraph (B)(1) of rule 5160-19-01 of the Administrative Code; 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 and not to exceed one million dollars.

(4) The "PCMH for kids bonus payment" is an annual retrospective payment for the highest performing PCMHs participating in the PCMH for kids program that meet quality and efficiency outcomes and perform additional bonus activities focused on improving pediatric care. PCMH practices are not eligible to earn this payment for the 2020 calendar year as they are not subject to the quality and efficiency metric thresholds identified in rule 5160-19-01 of the Administrative Code.

(a) To be eligible for the PCMH for kids bonus payment other than for calendar year 2020, the PCMH has to be a high performing PCMH relative to other PCMHs participating in the PCMH for kids program based on performance of risk-adjusted scoring of the following pediatric bonus activities, which will be determined by ODM and evaluated annually during each performance period. Specific information can be found on the ODM website, www.medicaid.ohio.gov.

(i) Additional supports for children in foster care the custody of a title IV-E agency;

(ii) Integration of behavioral health services:

(iii) School-based health care linkages;

(iv) Transitions of care; and

(v) Select wellness activities, including lead testing capabilities, community services and supports screening, tobacco cessation, fluoride varnish, and breastfeeding support.

(b) In the event of a tied score on the pediatric bonus activities, the PCMH will be ranked for bonus payment based upon the per cent of applicable quality and efficiency metrics passed. If there is a tie, then the following will be applied:

(i) The PCMHs are ranked based upon the highest average point performance over threshold across all applicable quality and efficiency metrics, rounded to the nearest per cent. If additional ties persist then;

(ii) Bonus payment will be split equally among each PCMH in the tie group.

(D) Payment conditions.

(1) A PCMH has to continue completing activities annually as defined in paragraph (G) of rule 5160-19-01 of the Administrative Code. If activities are not completed upon evaluation, payment under this rule terminates; and

(2) Except for the 2020 calendar year, at PCMH has to continue to meet efficiency and clinical quality metrics defined in paragraphs (H) and (I) of rule 5160-19-01 of the Administrative Code. If any of these metrics are not met, a warning will be issued. After two consecutive warnings, payment under this rule will be terminated.

(3) Except for the 2020 calendar year, a PCMH participating in PCMH for kids has to continue to meet clinical quality metrics defined in paragraphs (J) and (K) of rule 5160-19-01 of the Administrative Code. If any of these provisions are not met, a warning will be issued. After two consecutive warnings, PCMH for kids payments under this rule will be terminated.

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

Notes

Ohio Admin. Code 5160-19-02

Effective: 10/1/2021
Five Year Review (FYR) Dates: 10/17/2025
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 10/17/2020