Or. Admin. R. 410-149-0150 - CPC+ Alternative Payment Methodology

(1) The APM for Track 2 practices is a lump sum payment based upon a percentage of expected revenue calculated from annual reimbursements for FFS Medicaid members in the third and second year prior (e.g., For CY2021 annual reimbursements will be based on the average of CY2018 and CY2019). FFS payments shall be reconciled or adjusted down by the same percentage of the APM payment (e.g., 10 percent lump sum payment for one year causes FFS payments issued throughout the same year to be reduced by 10 percent):
(a) This structure is intended to allow Track 2 practices flexibility to deliver comprehensive care outside of the constraints of billable office visits;
(b) Track 1 practices are not eligible for the APM;
(c) Track 2 practices shall receive lump sum APM payments based on expected revenue for FFS Medicaid beneficiaries beginning in 2021;
(d) The Authority will apply the ratio of lump sum APM payments and FFS claims payments that the Track 2 practice selected with CMS for the CPC+ initiative, each demonstration year.
(2) Beginning in Year 5, CY2021, eligible practices shall receive the ratio selected from CMS of expected FFS payments from the Authority for FFS Medicaid beneficiaries as an upfront lump sum, based on the average of claims paid in CY2018 and CY2019.
(3) Practices participating in Track 2 shall continue to bill Oregon Medicaid FFS or CCOs through existing Authority protocols.
(4) The Authority will reconcile Medicaid APM dollars based upon actual CY2021 utilization.


Or. Admin. R. 410-149-0150
DMAP 31-2017(Temp), f. 7-28-17, cert. ef. 8-1-17 thru 1-27-18; DMAP 5-2018, adopt filed 01/24/2018, effective 1/24/2018; DMAP 66-2020, temporary amend filed 12/21/2020, effective 01/01/2021 through 06/18/2021; DMAP 22-2021, amend filed 06/10/2021, effective 6/18/2021

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: ORS 413.042 & 414.065

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