Ala. Admin. Code r. 560-X-37-.10

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-37-.10 - Payments To Primary Care Physicians And Delivering Healthcare Professionals Participating With The Alabama Coordinated Health Network

(1) Primary Care Physician (PCP) Groups.

(a) To participate with an Alabama Coordinated Health Network (ACHN), a PCP Group must engage with the ACHN as follows:

1. PCP Groups must sign two agreements beyond their Medicaid enrollment:

(i) A PCP Group Agreement with Alabama Medicaid; and

(ii) One agreement with an ACHN entity.

2. Over a twelve (12) month period, attend in person at least (2) quarterly Medical Management Meetings and one webinar/facilitation exercise with the ACHN's Medical Director. Attendance requirements can be met by having one PCP or Nurse Practitioner/Physician Assistant from the group attend;

3. Engage in ACHN initiatives centered around quality measures;

4. Review data provided by the ACHN to help achieve Alabama Medicaid and ACHN quality goals; and

5. Engage, as appropriate, in the ACHN's Multidisciplinary Care Team and the development of an individualized and comprehensive care plan.

(b) Participation requirements will be monitored on a monthly basis by the ACHNs and Alabama Medicaid. If an ACHN indicates a PCP group is not attending meetings or engaging as described above with the ACHN, Alabama Medicaid and the ACHN will make the determination to end the PCP's Group Agreement to participate in the ACHN Program.

(c) PCP groups who participate with an ACHN will be eligible for the following payments:

1. ACHN Participation Rate: PCP Groups are eligible to earn higher payments for 15 Evaluation and Management codes if they participate with the ACHNs. For a list of these E&M codes, see State Plan Attachment 4.19-B, page 2c.1. Rates are published on the Agency's website at www.medicaid.alabama.gov. The following provider groups are not eligible to receive ACHN Participation Rates: Federally Qualified Health Centers (FQHCs), Rural Health Centers (RHCs), OB/GYNs and nurse midwives, and nursing facilities.

2. Performance Bonus Payments: A performance payment pool has been established in the amount of $15 million annually to fund three (3) performance payments for participating PCP groups. The performance payments pool is allotted as follows: 50% for quality, 45% for cost effectiveness, and 5% for Patient Centered Medical Home (PCMH) Recognition. This bonus pool includes payments to FQHCs and RHCs.

3. Quality Performance Bonus Payments: All Participating PCP groups that meet or exceed annual quality benchmarks determined by Alabama Medicaid are eligible to receive a quarterly quality performance bonus payment.

(i) Quality payments for the period between October 1, 2019, and September 30, 2021, will be distributed to each PCP group based on the number of Medicaid recipients attributed to the PCP group, as determined in accordance with Rule 560-X-37-.09, for the prior quarterly period.

(ii) Quarterly payments after October 1, 2021, will be based on actual quality measure performance as soon as the previous calendar year's performance has been calculated. These payments will be distributed to each PCP group based on the number of Medicaid recipients attributed to the PCP group, as determined in accordance with Rule 560-X-37-.09, for the prior quarterly period.

4. Cost Effectiveness Performance Payments: All Participating PCP groups that meet or exceed cost effectiveness criteria established by the Agency are eligible to receive a quality cost effectiveness bonus payment.

(i) Quarterly cost effectiveness payments for the period between October 1, 2019, and December 31, 2020, will be distributed to each PCP group based on the number of Medicaid recipients attributed to the PCP group, as determined in accordance with Rule 560-X-37-.09, for the prior quarterly period.

(ii) Quarterly cost effectiveness payments after January 1, 2021, will be based on actual performance. The cost effectiveness performance calculation compares a 12-month per member per month (PMPM) to a risk-adjusted expected PMPM based on the costs of similar PCP groups that treat Medicaid recipients. Groups will be ranked by an efficiency score that is derived from actual PMPM versus the expected PMPM. All Participating PCP groups that meet a cost effectiveness score of less than 1.0 are eligible to receive a cost effectiveness bonus payment. The cost effectiveness score calculation methodology is outlined in Chapter 40 of the Provider Billing Manual on the Alabama Medicaid website. This calculation will occur as soon as the previous calendar year's performance has been calculated. These payments will be distributed to each PCP group based on the number of Medicaid recipients attributed to the PCP group, as determined in accordance with Rule 560-X-37-.09, for the prior quarterly period.

5. PCMH Recognition Performance Payments: The purpose of the PCMH Recognition performance payment is to incentivize providers to attain PCMH Recognition thereby ensuring Medicaid recipients are receiving care through a nationally recognized medical home model. All PCP groups who receive PCMH recognition will receive a quarterly bonus payment. The PCP group can obtain PCMH Recognition or certification through a nationally recognized entity such as National Committee for Quality Assurance (NCQA).

(i) Payments made for the period between October 1, 2019, and September 30, 2020, will be made based on the number of Medicaid Recipients attributed to the PCP group, as determined in accordance with Rule 560-X-37-.09, for the prior quarterly period.

(ii) Payments made after October 1, 2020, will be based on the PCP groups attestation of PCMH Recognition. The amount of the bonus payment will be distributed based on the number of Medicaid Recipients attributed to the PCP group, as determined in accordance with Rule 560-X-37-.09, for the prior quarterly period. Beginning October 1, 2020, if a PCP group does not meet PCMH Recognition, the Agency will not pay the PCMH bonus payment to the PCP group.

(2) Delivering Healthcare Professionals (DHCPs)

(a) To participate with an ACHN, a DHCP group must engage with an ACHN as follows:

1. A DHCP must sign a Delivering Healthcare Professional Group Agreement with an ACHN;

2. Provide data to the ACHN;

3. Engage in the development of the Medicaid recipient's care plan; and

4. Engage in the DHCP selection and referral process.

(b) Participation requirements will be monitored on a monthly basis by ACHNs and Alabama Medicaid. If the ACHN indicates a DHCP group is not providing data to the ACHNs, engaging in the development of the care plan, or engaging in the selection and referral process, Alabama Medicaid and the ACHN will make the determination to end the DHCP's contract. DHCPs who fail to meet these requirements will neither be referred Medicaid recipients by the ACHN nor will be able to provide maternity services to the ACHN population.

(c) DHCPs participating with the ACHN are eligible to receive a bonus payment for providing the following services:

1. an initial prenatal visit in the first trimester and/or

2. a post-partum visit.

Ala. Admin. Code r. 560-X-37-.10

Amended by Alabama Administrative Monthly Volume XXXVIII, Issue No. 05, February 28, 2020, eff. 4/13/2020.

Amended by Alabama Administrative Monthly Volume XXXIX, Issue No. 12, September 30, 2021, eff. 11/14/2021.

Amended by Alabama Administrative Monthly Volume XLI, Issue No. 02, November 30, 2022, eff. 1/14/2023.

Author: Patricia Toston, Program Manager, Network Provider Assistance Unit, Managed Care Operations

Statutory Authority: Social Security Act, Title XIX, State Plan, Attachment 4.19-B.