10209.1 DHCF shall administer two (2) incentive payment programs for My Health GPS entities, as follows:
(a) A person-centered plan of care incentive payment program, as described in § 10209.2; and(b) A pay- for-performance incentive program, as described in §§ 10209.3 through 10209.13.10209.2During the period beginning July 1, 2017 and ending October 31, 2017, all My Health GPS entities shall be eligible for a single incentive payment for each eligible beneficiary to support development of the person-centered plan of care. In order for the entity to receive the incentive payment, its My Health GPS provider(s) shall meet all requirements of § 10207.12 for each qualifying beneficiary within the period beginning July 1, 2017 and ending October 31, 2017.
10209.3 Each My Health GPS entity shall participate in the My Health GPS pay-for-performance incentive program for all four (4) quarters of each measurement year. If an entity is not enrolled in the My Health GPS program for all four (4) quarters of a measurement year, the following provisions regarding participation in the pay- for-performance incentive program apply:
(a) If a My Health GPS entity enrolls in the My Health GPS program after the first day of the first quarter of the measurement year, the entity shall not be eligible for the performance payment described in § 10209.13 for that measurement year, but shall receive the full amount of the percentage withheld for that measurement year, as described in § 10209.6; and(b) If a My Health GPS entity is enrolled in the My Health GPS program on the first (1st) day of the first quarter of the measurement year but is no longer enrolled in the program on the last day of the last quarter of the measurement year, the entity shall not be eligible for either the performance payment described in § 10209.13 or any portion of the percentage withheld for that measurement year, as described in § 10209.6.10209.4 A My Health GPS entity's performance in the pay- for-performance incentive program will be assessed against the entity's attainment or individualized improvement thresholds developed during the periods outlined in §§ 10208.3 and 10208.4.
10209.5 DHCF shall inform all My Health GPS entities of the attainment and individualized improvement thresholds for each of the measures outlined in § 10208.1(b) prior to the start of each measurement year of the pay- for -performance incentive program.
10209.6 The first (1st) measurement year for the pay- for-performance incentive program shall begin on October 1, 2019. My Health GPS entities shall be subject to a percentage withheld from every PMPM payment for services rendered during the measurement year, as follows:
(a) Measurement Year One (Fiscal Year 2020): Ten percent (10%);(b) Measurement Year Two (Fiscal Year 2021): Fifteen percent (15%); and(c) Measurement Year Three (Fiscal Year 2022) and all subsequent performance periods: Twenty percent (20%).10209.7My Health GPS entities shall be assessed based on either attainment or improvement on the measures described in § 10208.1(b) on an annual basis for the pay- for-performance incentive program. If a My Health GPS entity did not meet or exceed its attainment threshold, then DHCF shall assess whether the My Health GPS entity met or exceeded its individualized improvement threshold. The following guidelines are set forth below:
(a)A My Health GPS entity must meet or exceed the seventy- fifth (75th) percentile based on the attainment threshold; or(b) A My Health GPS entity must demonstrate a statistically significant improvement based on the individualized improvement threshold. A statistically significant improvement has a probability of 0.05 that the improvement was not due to random error. DHCF shall perform the appropriate statistical analysis (e.g., t-test) to determine that the performance between measurement years is a result that cannot be attributed to chance.10209.8 DHCF shall provide written notification of the attainment and individualized improvement thresholds to each My Health GPS entity after all measures are received and validated for the pay- for-performance incentive program.
10209.9 A My Health GPS entity may opt to aggregate its beneficiary population with another My Health GPS entity's population for the purposes of calculating attainment or improvement on any of the required measures described in § 10208.1(b) in the pay- for-performance incentive program subject to the following conditions:
(a) Each My Health GPS entity shall notify DHCF of its selection of the aggregation option no later than September 1st prior to the measurement year;(b)My Health GPS entities opting to aggregate their populations together shall do so for calculation of all measures during a given baseline or measurement year;(c)My Health GPS entities opting to aggregate their populations together must do so for calculation of all measures during a given baseline or measurement year;(d) Each My Health GPS entity shall report data that is identifiable for the My Health GPS entity's individual performance, along with the aggregated data;(e) A My Health GPS entity shall elect the option to aggregate annually and may change its selection, including opting against pooling or opting to pool with a different My Health GPS entity, on an annual basis; and(f) When a My Health GPS entity has opted to aggregate beneficiaries, performance is measured for the aggregated My Health GPS entity throughout the duration of the measurement year unless one (1) of the aggregated entities withdraws from the My Health GPS program during the measurement year. If one (1) of the My Health GPS entities that has opted to aggregate beneficiaries withdraws before the measurement year is complete, the remaining My Health GPS entity's performance will be measured based on the remaining My Health GPS beneficiaries.10209.10 For each measurement year, the maximum amount of funding available to qualifying My Health GPS entities for the pay-for-performance incentive program shall be equal to one and one-half (1.5) times the measurement year withhold amount percentage, as outlined in § 10209.6.
10209.11 To determine the My Health GPS entity's annual performance in the pay-for- performance incentive program, DHCF shall score each participating My Health GPS entity's performance in three (3) measurement domains. This scoring will be determined as follows:
(a) A maximum of one hundred (100) points will be awarded to each My Health GPS entity's across the efficiency, utilization, and process domains described in § 10208.1(b);(b) Each measure in the domain is assigned points by dividing the total points by the number of measures in each domain. Points for each domain are described in the table set forth in (c);(c)My Health GPS Entity Performance Measure Point Distribution Methodology |
Measurement Year1 (FY 2020) | Measurement Year 2 (FY 2021) | Measurement Year 3 and on (FY 2022) |
Total Efficiency Domain Points (allowed points per measure) | 50 (25) | 50 (25) | 50 (25) |
Total Utilization Domain Points (allowed points per measure) | 50 (16.66) | 50 (16.66) | 50 (16.66) |
Total Performance Points | 100 | 100 | 100 |
(d)Points for each measure shall be awarded in cases where a My Health GPS entity meets either the attainment or improvement threshold based on the prior measurement year's performance as described below:
(1) A My Health GPS entity shall receive points if it met or exceeded the seventy- fifth (75th) percentile attainment benchmark;(2) A My Health GPS entity performing below the attainment benchmark may be able to receive the allowed points per measure as described in (c) for each measure if it has met or exceeded its improvement threshold described in § 10209.7(b); and(3) If a My Health GPS entity neither attains nor improves performance on a given measure, zero (0) points will be awarded for that measure;(e)The amount of the incentive payment that a My Health GPS entity shall be eligible to receive shall be calculated as follows:
(1) Sum points awarded for each measure in the domain to determine the domain totals;(2) Sum domain totals to determine total performance points;(3) Divide total performance points by the maximum allowed points to determine the performance period percentage; and(4) The amount in (3) shall be multiplied by one and one-half (1.5) times the performance period withhold amount for the My Health GPS entity, calculated in accordance with the withhold amount percentage for the measurement year, as set forth in § 10209.6.10209.12 If My Health GPS entities have aggregated beneficiaries together for determination of performance in the pay- for-performance incentive program, the award percentage for the aggregated entities shall be applied to each My Health GPS entity's maximum incentive payment amount to determine the My Health GPS entities performance award individually.
10209.13Beginning with FY 2020, and annually thereafter, performance payments for the pay- for-performance incentive program shall be calculated and distributed after the conclusion of each measurement year once all measures are calculated and have been validated for each My Health GPS entity.
D.C. Mun. Regs. tit. 29, r. 29-10209
Final Rulemaking published at 64 DCR 636 (1/26/2018); amended by Final Rulemaking published at 66 DCR 005382 (4/26/2019)