Ohio Admin. Code 5160-19-02 - Comprehensive primary care (CPC) program: payments

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

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

(C) An eligible CPC entity may qualify for the following payments:

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

(a) Payment is in the form of a prospective risk-adjusted PMPM payment that is calculated for each attributed medicaid individual. Further detail regarding risk-adjustment can be found on the Ohio department of medicaid (ODM) website, www.medicaid.ohio.gov.

(b) Payment begins following enrollment and in accordance with the payment schedule determined by the Ohio department of medicaid (ODM).

(2) The "CPC for kids enhanced PMPM" is a payment to support the CPC entities participating in the CPC for kids program.

(a) Payment is in the form of a prospective flat PMPM payment per attributed medicaid pediatric individual except for those excluded in rule 5160-19-01 of the Administrative Code.

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

(3) The "CPC shared savings payment" is a payment for a CPC entity that meets quality, efficiency, and financial outcomes. to reward total cost of care savings.

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

(i) The CPC entity has to meet quality, efficiency, and financial outcomes outlined in rule 5160-19-01 of the Administrative Code;

(i)(ii) The CPC entity has at least sixty thousand member months in the performance period;

(ii)(iii) The CPC entity achieves savings on its total cost of care during the performance period compared to its own baseline total cost of care performance by performing in the top decile of all CPC entities based on total cost of care performance. The total cost of care for a CPC entity is calculated by summing all claims for a given patient, plus any PMPM payment that the CPC entity has received through the CPC program, minus the following exclusions and taking into account the overall risk status of the population. Baseline total cost of care calculations may be adjusted mid-performance year as necessary to reflect factors such as population acuity shifts. 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.

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

(b) The CPC 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 is determined by the CPC entity's total cost of care for its attributed medicaid individuals as defined in rule 5160-19-01 of the Administrative Code.

(ii) An annual retrospective bonus payment based on total cost of care for CPC entities in the top-performing decile, to be determined annually by ODM and not to exceed one million dollars.

(4) The "CPC for kids bonus payment" is an annual retrospective payment for the highest performing CPC entities participating in the CPC for kids program that meet quality and efficiency outcomes and perform additional bonus activities focused on improving pediatric care.

(a) To be eligible for the CPC for kids bonus payment, the CPC entity has to be a high performing CPC relative to other CPC entities participating in the CPC 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. More information on the CPC for kids program can be found on the ODM website, www.medicaid.ohio.gov.

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

(ii) Integration of behavioral health services.

(iii) School-based health care linkages.

(iv) Transitions of care.

(v) Oral evaluation, dental services.

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

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

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

(D) Payment and program participation conditions.

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

(2) A CPC entity has to continue to meet efficiency and clinical quality metrics defined in rule 5160-19-01 of the Administrative Code. If any of these metrics are not met in a program year, a warning will be issued. After two consecutive warnings program years of a metric not being met, entity participation in the program and , payment under this rule will be terminated.

(3) A CPC entity participating in CPC for kids has to continue to meet clinical quality metrics defined in 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 program years of a metric not being met, the , CPC for kids entity participation in the program and payments under this rule will be terminated.

(E) A CPC entity 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: 12/12/2024
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, 10/01/2021, 11/18/2022, 11/09/2023