10 Colo. Code Regs. § 2505-10-8.733
Current through Register Vol. 47, No. 17, September 10, 2024
Section 10 CCR 2505-10-8.733 - EPISODE BASED PAYMENTS8.733.1DEFINITIONS8.733.1.A.Episode means a defined group of related Medicaid-covered services provided to a specific patient over a specific period of time. A Maternal Episode includes the Delivery Episode Trigger; Prenatal Pre-Trigger Window; Delivery Trigger Window; and Post-Partum Post-Trigger Window. 1.Delivery Episode Trigger means the date of a qualifying live delivery event.2.Prenatal Pre-Trigger Window means the 280-day period prior to the delivery episode trigger window and includes all relevant care for the patient provided during that period.3.Delivery Trigger Window means the time period when the mother is in the hospital for the delivery episode trigger.4.Postpartum Post-Trigger Window means the 60-day time period following the delivery episode trigger window and includes all relevant care and any complications that might occur for the mother during that period.8.733.1.B.Episode Cohort means a Principal Accountable Provider's (PAP) maternity Episodes eligible for either positive or negative incentives after exclusions, cost outliers, and services not relevant to the Prenatal Pre-Trigger, Delivery Trigger, and Post-Partum Post-Trigger Windows have been removed.8.733.1.C.Gross Episode Performance means the aggregated average performance of a PAP compared to each prospective target set by each Threshold without the Department's share calculated, for either the Behavioral Health or Non-Behavioral Health subsets of Episodes.8.733.1.D.High-Risk Pregnancy means pregnancy that threatens the health or the life of the mother or her fetus. Risk factors can include existing health conditions, weight and obesity, multiple births, older maternal age, and other factors.8.733.1.E.Net Episode Performance means the Gross Episode Performance of a PAP multiplied by the Department's share of fifty percent, for either the Behavioral Health or Non-Behavioral Health subsets of Episodes.8.733.1.F.Performance Period means a twelve-month period, beginning on November 1 of each year, for which the Department will measure Episode performance of all providers delivering services during the course of a specific Episode. For an Episode to be included within the Performance Period, the end date for the Episode must fall within the Performance Period.8.733.1.G.Principal Accountable Provider (PAP) means the provider that is held accountable for both the quality and cost of care delivered to a patient for an entire Episode. PAPs for maternity Episodes are willing obstetrical groups who agree in writing to participate in the program with the Department.8.733.1.H.Threshold means the prospective cost target for performance for both the upper and lower incentive benchmarks for the Behavioral Health and non-Behavioral Health subsets within a PAP's Episode Cohort. 1.Acceptable means the dollar value such that a provider with an average reimbursement below the dollar value incurs a positive incentive payment.2.Commendable means the specific dollar value such that a provider with an average reimbursement below the dollar value is eligible for a positive incentive payment if all Quality Metrics linked to the incentive payment are met.8.733.1.I.Quality Metrics means measures determined by the Department that will be used to evaluate the quality of care delivered during a specific Episode, including the extent to which care reduces disparate outcomes based on race and ethnicity and improves patient experience.8.733.2MATERNITY8.733.2.A. Maternity Bundled Payment Pilot Program 1. Using Episode-based payments, the Department modifies its payment methodology for maternity services, as defined in Section 8.732, for PAPs to recognize the quality and efficiency of maternity services provided, including the extent to which services reduce health disparities and improve the patient experience.2. Maternity Episode definitions and appropriate Quality Metrics are based on evidence-based practices derived from peer-reviewed medical literature, public health data on infant and maternal morbidity and mortality and effective responses, historical provider performance, and clinical information furnished by providers rendering services during maternity Episodes.3. Medicaid-covered services during a maternity Episode will be included in the Prenatal Pre-Trigger Window, Delivery Trigger Window, and Post-Partum Post-Trigger Window. The services considered as a part of the episode shall not be limited solely to those provided by the PAP.4. The Department through a stakeholder advisory process that is majority currently or former Medicaid members who have received maternity services and majority people of color shall review the maternity bundled payment pilot. The process shall meet and review data on the maternity bundled payment pilot at least quarterly.8.733.2.B. Maternity Episode Program Incentive Payments 1. Incentive payments to a PAP are based upon an Episode Cohort within a Performance Period.2. Since program participation is voluntary, PAPs are only subject to positive incentives. Positive incentive payments may be made retrospectively after the end of the Performance Period.3. When calculating a PAP's Episode Cohort, the Department excludes the Episodes which have the presence of the following: a. The member is dually eligible for Medicare and Medicaid at any time during the Episode.b. Third-party liability on any claim within a maternity Episode.c. PAP provided no prenatal services for to the member.d. Member died during Episode.e. Incomplete set of claims for an Episode.f. No professional claim for delivery.4. When calculating a PAP's Episode Cohort, the Department will remove cost outliers via a statistical methodology determined by the Department's actuarial contractor.5. When calculating a PAP's Episode Cohort, the Department will remove services that are not part of the relevant care for the Prenatal Pre-Trigger, Delivery Episode, and Post-Partum Post-Trigger Windows.6. Each participating PAP will have two sets of Acceptable and Commendable Thresholds calculated based on their historical costs for Episodes.a. The first set of Thresholds will be calculated based on historical costs for Episodes that contain a flag for Behavioral Health (including Substance Use Disorder (SUD) or Mental Health).b. The second set of Thresholds will be calculated based on historical costs for Episodes that do not contain a flag for Behavioral Health (SUD and Mental Health).c. It is the responsibility of the PAP to review each set of Acceptable and Commendable Thresholds provided by the Department before the start of the Performance Period.7. Incentive payments for a PAP's Episodes within the Performance Period will be calculated in two separate subsets. a. The first subset comprises Episodes that have a flag for Behavioral Health (SUD or Mental Health).b. The second subset comprises Episodes that do not have a flag for Behavioral Health (SUD or Mental Health).8. In order for a PAP to be eligible for positive incentives for a subgroup, the PAP must do the following: a. Meet the Quality Metrics set for each Performance Period by the Department. The Department shall present on quality measures to the Program Improvement Advisory Committee (PIAC) before measures are tied to payment. Subject to data availability and quality limitations, the Department at a minimum shall monitor the following within the limitations of data availability and data quality:
ii. All cause readmissionsiii. Severe maternal morbidityiv. Maternal Gestational Hypertension, Pre-eclampsia, HELLP syndrome, eclampsiaThe Department shall review all findings through the stakeholder advisory process identified in 8.733.2.A (4). If warranted, the Department may update the list of quality metrics monitored. Subject to the limitations of data availability, if the Department seeks improved PAP performance for a quality metric, that quality metric may be tied to payment.
b. During the first year that a PAP joins the program, the PAP's performance relative to quality metrics (including metrics tied to payment) will only be tracked and reported to the provider to create a baseline. Starting the second year of a PAP's participation in the program, the Department will apply quality metrics tied to payment.c. In determining a PAP's incentive payments, starting the second year the Department will also consider whether the PAP provided the same or a greater number of services and/or resources to members within the subgroup who experience racism as compared to members in the subgroup who do not experience racism.9. If the PAP's aggregated average Gross Episode Performance for each subset is lower than each Commendable Threshold, the PAP shall receive a positive incentive payment.10. If the PAP's aggregated average Gross Episode Performance for each subset is higher than each Acceptable Threshold, the PAP will not be liable for a negative incentive payment as a financial penalty.11. If the average Episode reimbursement for each subset is between each set of Acceptable and Commendable Thresholds, the PAP shall not receive a positive incentive payment or incur a negative incentive payment.12. Incentive payments are separate from, and do not alter, the reimbursement methodology for Medicaid-covered services set forth in Department rules and guidance.13. Consideration of the aggregate cost and quality of care is not a retrospective review of the medical necessity of care rendered to any particular member.14. Nothing in this rule prohibits the Department from engaging in any retrospective review or other program integrity activity.15. PAPs may contest the Department's incentive payment determination. PAPs who contest the Department's determination must submit in writing the reason for contesting the determination within 60 calendar days of receiving the notice of payment. The Department will review all contested determinations within 30 calendar days of receipt of the notice. The PAP has the right to file an appeal with the Office of Administrative Courts in accordance with Section 8.050.3.8.733.2.C Maternity Bundled Payment Program Participation1. Participation is not mandatory in the Maternity Bundled Payment program for qualified obstetrical groups.2. Participation by obstetrical groups in the Maternity Bundled Payment program does not limit a patient's ability to change providers mid-episode for any reason,3. Medicaid-covered obstetrical groups who participate in the maternity bundled payment program will allow the Department to extract clinical data from their electronic medical records. Information extracted from electronic medical records will be used by the Department to monitor the quality of care and the number of services being provided to members within the subgroup who experience health disparities based on race and ethnicity.4. Obstetrical groups who participate in the maternity bundled payment will be required to participate in cultural competency training selected by the Department, to be inclusive of the importance of racial congruence between patients and providers and hiring and retention strategies for maintaining a diverse staff.5. Obstetrical groups that are interested in becoming PAPs will do the following:b. The Department will notify PAP applicants that it received their applications. The Department will contact applicants to arrange meetings for a collaborative review of their preliminary cost thresholds.c. Following this meeting, when the applicant reviews and accepts the program's cost thresholds, details, and requirements, the applicant may sign a Program Participation Agreement and a Thresholds Acceptance Letter to confirm their participation.