Chapter 5160-19 | Patient-Centered Medical Homes

Rule 5160-19-01 | Comprehensive primary care (CPC) program: eligible providers.

• Effective: November 18, 2022
• Promulgated Under: 119.03

(A) For purposes of rules 5160-19-01 and 5160-19-02 of the Administrative Code, the following definitions apply:

(1) "Attribution" is the process through which medicaid recipients are assigned to specific PCPs who are able to participate in the medicaid program in accordance with rule 5160-1-17.2 of the Administrative Code. ODM is responsible for attributing fee-for-service recipients; MCOs are responsible for attributing their enrolled recipients. PCMH practices CPC entities who are not able to participate in accordance with rule 5160-1-17.2 of the Administrative Code at the time of attribution or during the prospective payment period may not be attributed members or be eligible for payment until the next attribution period following the provider's reinstatement. The following hierarchy will be used in assigning recipients to PCPs under the PCMHCPC and PCMHCPC for kids program:

(a) The recipient's choice of provider.

(b) Claims data concerning the recipient.

(c) Other data concerning the recipient.

(2) "CPC attributed medicaid individuals" are Ohio medicaid recipients for whom PCPs have accountability under a CPC entity. A PCP's attributed medicaid individuals are determined by the Ohio department of medicaid (ODM) or medicaid managed care organizations (MCOs). All medicaid recipients are attributed except for:

(a) Recipients dually enrolled in Ohio medicaid and medicare;

(b) Recipients not eligible for the full range of medicaid benefits; and

(c) Recipients with third party benefits as defined in rule 5160-1-08 of the Administrative Code except for recipients with exclusively third party dental or vision coverage.

(d) Recipients enrolled in a prepaid inpatient health plan, as defined in 42 C.F.R. 438.2 (as in effect on October 1, 2021), under contract with ODM.

(e) Recipients attributed to other population health alternative payment models administered by ODM (e.g., comprehensive maternal care).

(3) "Baseline year" is a twelve month calendar year, typically two years preceding the performance period unless otherwise specified by ODM. More information about baseline years can be found at www.medicaid.ohio.gov.

(4) "Convener" is the practice responsible for acting as the point of contact for ODM and the practices who form a practice partnership.

(5) "CPC for kids" program is a voluntary enhancement to the CPC program focused on attributed pediatric medicaid covered individuals under twenty-one years of age.

(6) "Eligible provider" is as defined in rule 5160-1-17 of the Administrative Code.

(7) "A Patient-centered medical home (PCMH)" is a team-based care delivery model led by primary care practitioners (PCPs) who comprehensively manage the health needs of individuals. Provider enrollment in the Ohio department of medicaid (ODM) PCMH program, known as the comprehensive primary care (CPC) program is voluntary. A CPC entity may be a single practice or a practice partnership.

(8) "Performance period" is the twelve month calendar year period of participation in the CPC program by an enrolled CPC entity. An enrolled CPC entity's first performance period begins the first of January after their enrollment in the program.

(9) "Practice Partnership" is a group of practices participating as a CPC entity whose performance will be evaluated as a whole. The practice partnership has to meet the following provisions:

(a) Each member practice will have a minimum of one hundred fifty attributed medicaid individuals determined using claims-only data;

(b) Member practices will have a combined total of five hundred or more attributed individuals determined using claims-only data at each attribution period;

(c) Member practices will have a single designated convener that has participated as a CPC entity for at least one year;

(d) Each member practice will acknowledge to ODM its participation in the partnership; and

(e) Each member practice will agree that summary-level practice information will be shared by ODM among practices within the partnership.

(B) The following eligible providers may participate in ODM's CPC program through their contracts with MCOs or provider agreements for participation in medicaid fee-for-service in accordance with rule 5160-1-17.2 of the Administrative Code:

(1) Individual physicians and practices;

(2) Professional medical groups;

(3) Rural health clinics;

(4) Federally qualified health centers;

(5) Primary care clinics.

(6) Public health department clinics.

(7) Professional medical groups billing under hospital provider types.

(C) The following eligible providers may participate in the delivery of primary care activities or services in the CPC program:

(1) Medical doctor (MD) or doctor of osteopathy (DO) as defined in section 4731.14 of the Revised Code with any of the following specialties or sub-specialties:

(a) Family practice;

(b) General practice;

(c) General preventive medicine;

(d) Internal medicine;

(e) Pediatric;

(f) Public health; or

(g) Geriatric.

(2) Clinical nurse specialist or certified nurse practitioner as defined in section 4723.41 of the Revised Code and has any of the following specialties:

(a) Pediatric;

(b) Adult health;

(c) Geriatric; or

(d) Family practice.

(3) Physician assistant as defined in section 4730.11 of the Revised Code.

(D) To be eligible for enrollment in the CPC program, the CPC will have at least five hundred attributed medicaid individuals determined using claims-only data, attest that it will participate in learning activities as determined by ODM or its designee, and share data with ODM and contracted MCOs;

(E) To be eligible for enrollment in the CPC for kids program, the CPC entity will:

(1) Be a CPC entity that participates in ODM's CPC program for the same performance period; and

(2) Have at least one hundred fifty attributed pediatric medicaid individuals determined using claims-only data.

(F) It is the responsibility of an enrolled CPC entity to complete activities within the time frames stated in this rule and have written policies where specified. Further descriptions of these activities can be found on the ODM website, www.medicaid.ohio.gov. Upon enrollment and on an annual basis, the CPC entity is expected to attest that it will:

(1) Complete the "twenty-four-seven and same-day access to care" activities in which the PCMH will:

(a) Offer at least one alternative to traditional office visits to increase access to the patient care team and clinicians in ways that best meet the needs of the population. This may include, but is not limited to, e-visits, phone visits, group visits, home visits, alternate location visits, or expanded hours in the early mornings, evenings, and weekends.

(b) Within twenty-four hours of initial request, provide access to a primary care practitioner with access to the attributed medicaid individual's medical record; and

(c) Make clinical information of the attributed medicaid individual available through paper or electronic records, or telephone consultation to on-call staff, external facilities, and other clinicians outside the practice when the office is closed.

(2) Complete the "risk stratification" activities in which the CPC entity will have a developed method for documenting patient risk level that is integrated within the attributed medicaid individual's record and has a clear approach to implement this across the practice's entire patient panel.

(3) Complete the "population health management" activities in which the CPC entity will identify attributed medicaid individuals in need of preventive or chronic services and begin outreach to schedule applicable appointments or identify additional services needed to meet the needs of the attributed medicaid individual.

(4) Complete the "team-based care delivery" activities in which the CPC entity will define care team members, roles, and qualifications and provide various care management strategies in partnership with payers, ODM, and other providers as applicable for attributed medicaid individuals in specific segments identified by the CPC entity.

(5) Complete the "care coordination" activities in which the CPC entity will identify and close gaps in care and refer attributed medicaid individuals for further intervention as needed, including referrals to managed care organizations or community resources as appropriate.

(6) Complete the "follow-up after hospital discharge" activities in which the CPC entity will have established relationships with all emergency departments and hospitals from which it frequently receives referrals and has an established process to ensure a reliable flow of information.

(7) Complete the "tests and specialist referrals" activities in which the CPC entity will have established bi-directional communication with specialists, pharmacies, laboratories, and imaging facilities necessary for tracking referrals.

(8) Complete the "patient experience" activities in which the CPC entity will:

(a) Orient all attributed medicaid individuals to the practice and incorporate patient preferences in the selection of a primary care provider to build continuity of attributed medicaid individual relationships throughout the entire care process;

(b) Ensure all staff who provides direct care or otherwise interacts with attributed medicaid individuals completes cultural competency training, as deemed acceptable by ODM, within twelve months of program enrollment and annually thereafter;

(c) Ensure that new staff who will provide direct care or otherwise interact with attributed medicaid individuals complete cultural competency training within ninety days of their start date;

(d) Routinely assess demographics and adapt training needs based on demographics;

(e) Assess its approach to attributed medicaid individual experience and cultural competency at least once annually through the use of the patient and family advisory council (PFAC) or other quantitative and qualitative means, such as focus groups or a patient survey, that covers access to care, communication, coordination, and whole person care and self-management support; and

(f) Use the information collected pursuant to paragraph (G)(8)(e) of this rule to identify and act on opportunities to improve attributed medicaid individual experience and reduce cultural disparities, including disparities in the identification, treatment, and outcomes related to chronic conditions such as asthma, diabetes, and cardiovascular health. The CPC entity will report findings and opportunities to attributed medicaid individuals, the PFAC, payers, and ODM.

(9) Complete the "community services and supports integration" activities in which the CPC entity will identify medicaid covered individuals in need of community services and supports and maintains a process to connect attributed medicaid individuals to necessary services.

(10) Complete the "behavioral health integration" activities in which the CPC entity will use screening tools to identify attributed medicaid individuals in need of behavioral health services, tracks and follow up on behavioral health service referrals, and has a planned improvement strategy for behavioral health outcomes.

(11) Cooperate with and grant access to ODM or its designee for the purpose of conducting activity requirement evaluations.

(G) It is the responsibility of a CPC entity to pass a number of the following efficiency metrics representing at least fifty per cent of applicable metrics, to be evaluated annually at the end of each performance period. Further details regarding these metrics can be found on the ODM website, www.medicaid.ohio.gov.

(1) Inpatient admission for ambulatory care sensitive conditions (ACSCs);

(2) Emergency room visits per one thousand;

(3) Behavioral health related inpatient admissions per one thousand; and

(4) Adherence to the single preferred drug list.

(H) It is the responsibility of a CPC entity to pass a number of the following clinical quality metrics representing at least fifty per cent of applicable metrics, to be evaluated annually at the end of each performance period. Further details regarding these metrics can be found on the ODM website, www.medicaid.ohio.gov.

(1) Well-child visits in the first fifteen months of life;

(2) Child and adolescent well-child visits for members who are three to eleven years of age;

(3) Child and adolescent well-child visits for members who are twelve to seventeen years of age;

(4) Weight assessment and counseling for nutrition and physical activity for children and adolescents. Body mass index (BMI) assessment for children and adolescents;

(5) Timeliness of prenatal care;

(6) Live births weighing less than two thousand five hundred grams;

(7) Postpartum care;

(8) Breast cancer screening;

(9) Cervical cancer screening;

(10) Controlling high blood pressure;

(11) Asthma medication ratio;

(12) Statin therapy for attributed medicaid individuals with cardiovascular disease;

(13) Comprehensive diabetes care; HbA1c poor control (greater than nine per cent);

(14) Comprehensive diabetes care: blood pressure control;

(15) Comprehensive diabetes care: eye exam;

(16) Antidepressant medication management;

(17) Follow-up after hospitalization for mental illness;

(18) Preventive care and screening: tobacco use, screening and cessation intervention;

(19) Initiation and engagement of alcohol and other drug dependence treatment; and

(20) Well visits for members who are eighteen to twenty-one years of age.

(I) It is the responsibility of a CPC entity participating in CPC for kids to also pass at least fifty per cent of the applicable metrics from the following list of clinical quality metrics, to be evaluated annually at the end of each performance period. Further details regarding these metrics can be found on the ODM website, www.medicaid.ohio.gov.

(1) Lead screening in children;

(2) Childhood immunization status;

(3) Immunizations for adolescents;

(4) Well-child visits in the first fifteen months of life;

(5) Child and adolescent well-child visits for members who are three to eleven years of age;

(6) Child and adolescent well-child visits for members who are twelve to seventeen years of age;

(7) Weight assessment and counseling for nutrition and physical activity for children and adolescents. BMI assessment for children and adolescents; and

(8) Well visits for members who are eighteen to twenty-one years of age.

(J) It is the responsibility of a CPC entity participating in CPC for kids to also pass at least one of the following clinical quality metrics when applicable, to be evaluated annually at the end of each performance period. Further details regarding these metrics can be found on the ODM website, www.medicaid.ohio.gov.

(1) Lead screening in children;

(2) Childhood immunization status; and

(3) Immunizations for adolescents.

(K) A CPC entity may utilize reconsideration rights as stated in rules 5160-70-01 and 5160-70-02 of the Administrative Code to challenge a decision of ODM concerning CPC or CPC for kids program enrollment or eligibility.

Last updated September 29, 2023 at 2:40 PM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 10/17/2025
Prior Effective Dates: 10/1/2021

Rule 5160-19-02 | Comprehensive primary care (CPC) program: payments.

• Effective: November 18, 2022
• Promulgated Under: 119.03

(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 by using 3M clinical risk grouping (CRG) software to categorize the individual into one of the following risk tiers:

(i) Healthy individuals including those with a history of significant acute diseases or a single minor chronic disease;

(ii) Individual with minor chronic diseases in multiple organ systems, significant chronic disease, or significant chronic diseases in multiple organ systems;

(iii) Individual with dominant chronic diseases in three or more organ systems, metastatic malignancy, or catastrophic condition.

(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 per-member-per-month (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;

(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.

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

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

(ii) The CPC entity can achieve savings on its total cost of care during the performance period compared to its own baseline total cost of care performance, or 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. 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; and

(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 will be determined by several factors including the PCMH's total cost of care for its attributed medicaid individuals as defined in rule 5160-19-01 of the Administrative Code; and

(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. Specific information 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; and

(v) Select wellness activities, including lead testing capabilities, community services and supports screening, tobacco cessation, fluoride varnish, and breastfeeding support.

(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 per cent 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 per cent. If additional ties persist then;

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

(D) Payment 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, payment under this rule terminates; and

(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, a warning will be issued. After two consecutive warnings, 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, CPC for kids 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.

Last updated September 29, 2023 at 2:40 PM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 10/17/2025
Prior Effective Dates: 10/1/2021

Rule 5160-19-03 | Comprehensive maternal care program.

• Effective: November 18, 2022
• Promulgated Under: 119.03

The "comprehensive maternal care (CMC) program" is a maternal and infant support program that utilizes a comprehensive care coordination and service model incorporating supportive services for expectant and postpartum medicaid eligible individuals to reduce adverse birth and infant outcomes.

(A) For purposes of Chapter 5160-19 of the Administrative Code, the following definitions apply:

(1) "Attribution" is the process through which the Ohio department of medicaid (ODM) or its designee assigns eligible individuals to a specific CMC entity.

(2) "CMC attributed medicaid individuals" are the eligible pregnant and postpartum Ohio medicaid recipients for whom an entity eligible under this rule has accountability for coordinating and ensuring the delivery of CMC program activities. All eligible individuals will be attributed except for:

(a) Individuals who are currently receiving another care coordination service that substantially duplicates those activities provided under this program.

(b) Individuals with a limited medicaid benefit plan other than presumptive eligibility for pregnant individuals.

(c) Individuals dually enrolled in Ohio medicaid and medicare.

(d) Individuals with third party benefits as defined in rule 5160-1-08 of the Administrative Code except for those with exclusively dental or vision coverage.

(3) "Comprehensive maternal care entity" (CMC entity) is the primary entity which meets the criteria described in this rule and is responsible for meeting CMC program activities for attributed medicaid individuals. The following medicaid providers are eligible to participate and receive payment under this rule:

(a) Professional medical groups as defined in Chapter 5160-1 of the Administrative Code.

(b) Federally qualified health centers (FQHC) and rural health clinics (RHC) as defined in Chapter 5160-28 of the Administrative Code.

(c) Clinics as defined in Chapter 5160-13 of the Administrative Code.

(d) Professional medical groups billing under hospital provider types.

(4) "Electronic pregnancy risk assessment form" (e-PRAF) is the electronic version of ODM form 10207 "pregnancy risk assessment form" (PRAF) that is submitted through the web portal designated by ODM.

(5) "Electronic report of pregnancy" (e-ROP) is the electronic version of ODM form 10257, "report of pregnancy" (ROP) that is submitted through the web portal designated by ODM.

(6) "Eligible provider" is as defined in rule 5160-1-17 of the Administrative Code.

(B) To be eligible and remain eligible for enrollment and participation as a CMC entity for payment in each program year, the CMC entity will:

(1) Have an active Ohio medicaid provider agreement in accordance with rule 5160-1-17.2 of the Administrative Code;

(2) Have provided prenatal and perinatal services to at least one hundred fifty pregnant and postpartum individuals under the same tax identification number, as identified through ODM data sources; and

(3) Apply to become a CMC entity. ODM reserves the right to deny any enrollment application it determines is not in compliance with the activities in this rule. An applicant may seek reconsideration pursuant to rule 5160-70-02 of the Administrative Code if ODM has denied a CMC program enrollment application.

(C) At the time of enrollment, the applicant attests that for the duration of its participation, it will do all of the following:

(1) Perform the activities identified in this rule.

(2) Have at least one practitioner from each of the following categories on staff or contracted with the entity:

(a) A practitioner with prescribing authority in the state of Ohio;

(b) A registered nurse (RN) or licensed practical nurse (LPN); and

(c) A case manager to lead the care coordination relationship and serve as the primary point of contact for the attributed medicaid individual.

(3) Demonstrate organizational commitment to integration of physical and behavioral health care by meeting one of the following:

(a) Employ or have under contract one or more licensed behavioral health care clinicians;

(b) Have an integrated care agreement such as a contract or memorandum of understanding with a behavioral health care entity;

(c) Have an ownership or membership interest in a provider organization where primary and behavioral health care services are integrated within the facility structure or entity, and are readily available to attributed medicaid individuals; or

(d) Have accreditation by a national accrediting entity as an integrated primary care-behavioral health provider.

(4) Integrate services of community resources and other practitioners including non-physician licensed or certified behavioral health practitioners described in rule 5160-8-05 of the Administrative Code.

(5) Conduct the following cultural competency activities to advance health equity:

(a) Ensure all clinical and professional staff who provide direct care to or interact with patients complete cultural competency training, meeting criteria established by ODM within six months of program enrollment and annually thereafter and for new employees within thirty calendar days of start date; and

(b) At least annually, assess the demographics of patients served, including race, ethnicity, and language, and adapt training needs for staff based on the results of the assessment.

(6) In the delivery of the CMC program activities, ensure appropriate measures are taken to protect the safety and confidentiality of attributed medicaid individuals in accordance with all state and federal regulations.

(7) Establish or adapt a patient and family advisory council to include members who reflect the demographics of the attributed medicaid individuals served.

(8) Participate in learning activities as determined by ODM or its designee and share data with ODM and contracted managed care organizations (MCOs).

(9) Review quarterly and annual reports as specified by ODM.

(10) Actively use an electronic health record (EHR) in clinical services.

(11) Have the ability to share, receive, and use electronic data from a variety of sources with other health care providers, ODM, and the MCOs.

(12) Have the ability to submit prescriptions electronically.

(13) Ensure than an e-PRAF is submitted for every pregnant individual.

(D) Attribution.

(1) The following hierarchy will be used in attributing individuals to a CMC entity:

(a) The eligible individual's choice of provider identified through the completion of the PRAF or e-PRAF.

(b) Pregnancy or postpartum related claims data concerning the eligible individual.

(c) Primary care provider relationship.

(d) Other data concerning the eligible individual such as geographic location.

(2) All pregnant and postpartum medicaid individuals will be assigned to either of the following risk tiers:

(a) Pregnant or postpartum individuals who:

(i) Are determined to be progesterone eligible as evidenced on the PRAF;

(ii) Are at risk of pre-term birth based on having had a prior pre-term birth or a shortened cervix as evidenced by vital statistics data or claims history;

(iii) Live in an area determined to have the least access to critical services according to the most recent Ohio opportunity index (OOI); or

(iv) Are considered medically complex as evidenced by claim history indicating substance use disorder, asthma, diabetes, lupus, chronic kidney disease, advanced maternal age (individuals over forty years of age), or cardiovascular disease.

(b) Pregnant or postpartum individuals up to three months postpartum who do not qualify under the previous tier.

(3) At any time, the eligible individual may choose a specific CMC entity or request to be re-attributed to a different CMC entity by submitting a request to the MCO, ODM or its designee.

(4) Eligible individuals may opt-out of the CMC program and may opt-in at any time by making a request to the MCO, ODM, or its designee.

(E) It is the responsibility of the CMC entity, upon enrollment and on an annual basis, to attest that it will meet the following provisions:

(1) Risk stratification. It is the responsibility of the CMC entity to:

(a) Use risk stratification information from multiple sources (including payers, e-PRAF, screenings tools, electronic health records, and patient history) to risk stratify patients and integrate this information into clinical records and care plans; and

(b) Perform maternal depression screens and use screening tools such as social determinants of health, screenings, brief intervention, and referral to treatment (SBIRT) at routine intervals to identify patients in need of, and connect them to, community services and supports.

(2) Enhanced access. It is the responsibility of the CMC entity to:

(a) Expedite the first prenatal visit by:

(i) Offering appointments within seven calendar days of the patients initial request; and

(ii) Establishing a process to reduce the gestational age at the first prenatal appointment with the overall goal of achieving the first appointment by the ninth week of gestation.

(b) Offer at least one alternative to traditional office visits to increase access to the patient care team and clinicians in ways that best meet the needs of the population. This may include e-visits, telehealth, phone visits, group visits, home visits, alternate location visits, or expanded hours in the early mornings, evenings, or weekends;

(c) Within one business day of initial request, provide access to a maternal care provider with access to the patient's medical record; and

(d) Make patient clinical information available through paper or electronic records, or telephone consultation to on-call staff, external facilities, and other clinicians outside the entity when the office is closed.

(3) Patient engagement. It is the responsibility of the CMC entity to:

(a) Implement strategies to engage patients early in their care and encourage them to be active participants in their care delivery;

(b) Implement specialized outreach strategies for pregnant individuals who are attributed to, but have not been seen by, the CMC;

(c) Deliver services in a manner that addresses the social, cultural, and linguistic needs of patients with specific attention to populations with high rates of infant and maternal mortality;

(d) Implement procedures that acknowledge patient consent and choice regarding referrals for needed treatment, community, and other supports;

(e) Assure patient consents are obtained to support exchange of information in compliance with state and federal regulations; and

(f) Establish partnerships with primary care practitioners and payers in order to strengthen the referral process of the CMC entity.

(4) Team based care delivery. It is the responsibility of the CMC entity to:

(a) Define care team members, roles, and qualifications with specific input from the patient regarding team composition (e.g., obstetricians, primary care, behavioral health, pediatricians, doulas, midwives, community workers, care managers, payers and community partners, as applicable);

(b) Establish care team meetings and planned, formal communication (including sharing of care plan documentation) among team members for highest risk patients;

(c) Have a process during the individuals prenatal period to assemble a team of providers who will care for the individual and baby during the postpartum period;

(d) Have active relationships with providers and community resources based on patient population needs; and

(e) Provide various care management strategies in partnership with payers, ODM and other providers, as applicable.

(5) Care management plan. It is the responsibility of the CMC entity to:

(a) Create, maintain, and update care plans and clinical documentation such as progress notes for the highest risk pregnant individuals which includes necessary key elements including integrated behavioral health elements, as applicable; and

(b) Identify key activities that need action or follow up by care team members.

(6) Patient experience. It is the responsibility of the CMC entity to:

(a) Have a process to ensure continuity in relationships and care throughout the entire care process including:

(i) A plan to transition patients to appropriate providers and resources as they move through the care continuum; and

(ii) A process to complete a transfer of care (in person or by telephone) with the CMC entity, the patient and members of the care team, specifically the individuals primary care practitioner, pediatric primary care for the baby, behavioral health provider, and community partners as appropriate.

(b) Assess its approach to improving the patient experience at least once annually through quantitative and qualitative means, including the patient and family advisory council, covering such topics as access to care, cultural competence, holistic care, and effective communication;

(c) Use the collected information to identify and act on opportunities to improve patient experience and reduce disparities; and

(d) Report findings and opportunities for improvement to patients, patient and family advisory council, payers, and ODM.

(7) Follow-up after hospital discharge. It is the responsibility of the CMC entity to:

(a) Establish relationships with emergency departments (EDs) and hospitals from which it frequently sends and receives referrals and has an established process to ensure a reliable flow of information;

(b) Proactively and consistently obtain patient discharge summaries from hospitals and other facilities, and connect information from discharge summaries to broader entity systems for highest risk tier patients; and

(c) Track patients receiving care at hospitals and EDs, proactively contact patients for appropriate follow-up care given the cause of admission within an appropriate period following a hospital admission or emergency department visit.

(8) Community integration. It is the responsibility of the CMC entity to:

(a) Identify local entities that can help address social and emotional needs of patients and integrate them into activities described in paragraph (F) of this rule, as appropriate;

(b) Participate directly or indirectly in state and local infant and maternal mortality efforts; and

(c) Integrate community services and supports into broader entity systems, including risk stratification, care management plan, and population health management.

(9) Population health management. It is the responsibility of the CMC entity to:

(a) Identify individuals in need of medical, behavioral, or community support services to drive best-evidence care using multifaceted outreach efforts;

(b) Track and follow up on referrals to medical, behavioral health, and community service providers and ensure no gaps in care;

(c) Actively review maternal and infant health outcome measures for the CMC entity, affiliated health system, etc.; and

(d) Have a planned strategy to improve maternal and infant health outcomes segmented by high risk subpopulations, including a planned strategy to reduce disparities in outcomes.

(F) It is the responsibility of the CMC entity to pass at least fifty percent of the following clinical quality measures, to be evaluated annually at the end of each performance period. Further details regarding these metrics can be found on the ODM website, www.medicaid.ohio.gov.

(1) Hepatitis B screening.

(2) Maternal primary care visit.

(3) HIV screening.

(4) TDAP vaccine.

(5) Tobacco cessation.

(6) Postpartum care.

(G) The CMC entity may qualify to access the following payments:

(1) The CMC per-member-per-month (PMPM) is a payment to support the CMC entity. Payment is in the form of a prospective PMPM payment that will be calculated for each attributed medicaid individual using ODM's risk tier file to categorize individuals in one of the two risk tiers. Specific information about this payment can be found on the ODM website, www.medicaid.ohio.gov.

(2) The CMC quality add-on payment is made to the CMC entities who meet quality outcomes. Specific information about this payment can be found on the ODM website, www.medicaid.ohio.gov.

(H) Penalties.

(1) It is the responsibility of the CMC entity to continue meeting all provisions as defined in this rule, including those contained in the described attestations. If these provisions are not met, payment under this rule is subject to termination.

(2) It is the responsibility of the CMC entity to continue meeting clinical quality measures defined in this rule. If any of these provisions are not met, a warning will be issued. After two consecutive warnings, payment under this rule will be terminated.

(3) A CMC entity may seek reconsideration pursuant to rule 5160-70-02 of the Administrative Code to challenge decisions by ODM to terminate payment described in this rule.

Last updated November 18, 2022 at 8:24 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 11/18/2027

Rule 5160-19-04 | Episode based payments.

• Effective: February 3, 2022
• Promulgated Under: 119.03

(A) Excluding calendar years 2020, 2021, and 2022, all medicaid managed care plans, providers under contract with medicaid managed care plans, and medicaid providers who participate in the medicaid fee-for-service program will participate in episode-based payments. This participation is limited to those episodes in which the provider renders services.

(B) Definitions.

(1) An "episode" is a defined group of related medicaid covered services provided to a specific patient over a specific period of time. The characteristics of an episode will vary according to the medical condition for which a recipient has been treated. Detailed descriptions and definitions for each episode are found in the Ohio medicaid payment innovation website located at www.medicaid.ohio.gov.

(a) "Episode type" means a diagnosis, health care intervention, or condition which characterizes the episode.

(b) For each episode type there are specific parameters that define the episode including:

(i) "Episode trigger" means those diagnosis or procedures and corresponding claim types and care settings that characterize a potential episode.

(ii) "Pre-trigger window" means the time period prior to an applicable trigger event and includes all relevant care for the patient.

(iii) "Trigger window" means the duration of the potential trigger event and includes all care provided.

(iv) "Post trigger window" means the time period following the trigger event and includes all relevant care and any complications that might occur.

(v) "Episode level exclusions" means patient characteristics, comorbidities, diagnoses or procedures that may potentially indicate a type of risk that, due to its complexity, cost, or other factors, should be excluded entirely rather than adjusted.

(vi) "Potential risk factors" means those patient characteristics, comorbidities, diagnosis or procedures that may potentially indicate an increased level of risk for a given patient in a specific episode.

(vii) "Quality metrics" means measures determined by the department that will be used to evaluate the quality of care delivered during a specific episode.

(2) "Performance period" means a twelve-month period, beginning on the first day of a calendar 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 it has to fall within the performance period. Due to the COVID-19 emergency, there will be no performance period during which the department measures episode performance for calendar years 2020, 2021, and 2022.

(3) "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. The department designates a PAP based on factors such as decision-making responsibilities, influence over other providers, and episode expenditures.

(4) "Thresholds" are the upper and lower incentive benchmarks for an episode of care.

(a) "Acceptable" means the specific dollar value for each specific episode such that a provider with an average risk-adjusted reimbursement above the dollar value incurs a negative incentive payment.

(b) "Commendable" means the specific dollar value for each specific episode such that a provider with an average risk-adjusted reimbursement below the dollar value is eligible for a positive incentive payment if all quality metrics linked to the incentive payment are met.

(c) "Positive incentive limit" means a level set to avoid the risk of incentivizing care delivery at a cost that could compromise quality.

(C) Through the use of episode-based payments, the department provides incentive payments to recognize the quality, efficiency, and economy of services provided in the course of an episode.

(D) Episode definitions and appropriate quality measures are based on evidence-based practices derived from peer-reviewed medical literature, historical provider performance, clinical information furnished by providers of the care, and services typically rendered during the episodes of care.

(E) Any medicaid covered services provided in the delivery of care for an episode may be included in the calculation of the average risk-adjusted episode reimbursement. The services considered need not be limited solely to those provided by the PAP.

(F) For each PAP, the department calculates the average risk-adjusted episode reimbursement for each episode that occurs within the performance period. The average risk-adjusted episode reimbursement is specific to the episode type, and is derived in the following manner:

(1) All episodes ending within a performance period are identified for each potential PAP and the total reimbursement for each episode is calculated based on related covered services delivered during the duration of each episode.

(2) The department excludes certain episodes in measuring a PAP's performance.

(a) Business exclusions are non-clinical reasons for excluding an episode. Business exclusions for each episode are found within the episode definitions at the Ohio medicaid payment innovation website.

(b) Clinical exclusions include characteristics of the patient or episode. Clinical exclusions for each episode are found within the episode definitions at the Ohio medicaid payment innovation website.

(3) For the episodes that remain after business exclusions and clinical exclusions are applied, the department excludes costs that are not attributable to the episode cost of care for the medicaid recipient.

(4) After the excluded episodes and costs are removed from the episodes assessed for the performance year, the department applies any risk adjustments necessary to enable comparison of a PAP's performance relative to the performance of other providers in a way that takes patient health risk factors and other health complications into sufficient consideration. Risk adjustments are specific to each episode as described at the Ohio medicaid payment innovation website.

(5) The average risk-adjusted reimbursement of all episodes for the PAP during the performance period will be compared to thresholds established by the department.

(G) Incentive payments to a PAP are based upon episodes that end within a performance period. Incentive payments may be positive or negative and are calculated and made retrospectively after the end of the performance period. Incentive payments are based on the aggregate of valid, paid claims across a PAP's episodes and are not relatable to any individual provider's claim for payment. A PAP has to have a minimum volume of episodes during the course of a performance period in order to be eligible for a positive or negative incentive payment. Due to the COVID-19 emergency, and in accordance with paragraph (B)(2) of this rule, PAPs will not be eligible for incentive payments for services provided during calendar years 2020, 2021, and 2022.

For each PAP for each applicable episode type:

(1) Performance will be aggregated and assessed over a specific period of time. For each PAP, the average risk-adjusted episode reimbursement across all relevant episodes completed during the performance period will be calculated, based on the set of services included in the episode definition.

(2) If the PAP's average risk-adjusted episode reimbursement is lower than the commendable threshold and the PAP has documented that the quality requirements established by the department for each episode type have been met, the department will make a positive incentive payment to the PAP. This incentive payment will be based on the difference between the PAP's average risk-adjusted episode reimbursement and the commendable threshold.

(3) If the PAP's average risk-adjusted episode reimbursement is higher than the acceptable threshold, the PAP will incur a negative incentive payment. This negative incentive payment will be based on the difference between the PAP's average risk-adjusted episode reimbursement and the acceptable threshold.

(4) If the average risk-adjusted episode reimbursement is between the acceptable and commendable thresholds, the PAP will not receive a positive incentive payment or incur a negative incentive payment.

(H) Threshold determination.

Thresholds are determined by taking into consideration several factors, including the potential to improve patient access, and the level and type of practice pattern changes essential for performance improvement.

(1) The acceptable threshold is set such that average cost per episode above the acceptable threshold reflects a PAP's unacceptable variation from typical performance without clinical justification.

(2) The commendable threshold is set such that outperforming the commendable threshold represents efficient, quality care.

(I) For each episode type, the department applies quality metrics to evaluate the quality of care delivered during the episode and applies these metrics to providers that are eligible for positive incentive payments in order to avoid the risk of incentivizing care delivery at a cost that could compromise quality. Included are quality metrics reflecting certain standards which support the delivery of adequate care during the course of the episode.

(J) Incentive payments are separate from, and do not alter, the reimbursement methodology for medicaid covered services set forth in department rules located in agency 5160 of the Administrative Code.

(K) Consideration of the aggregate cost and quality of care is not a retrospective review of the medical necessity of care rendered to any particular patient.

(L) Nothing in this rule prevents the department from engaging in any retrospective review or other program integrity activity.

(M) PAPs cannot make use of hearing rights under Chapter 119. of the Revised Code to challenge a decision made by the department; however, reconsideration rights as stated in rules 5160-70-01 and 5160-70-02 of the Administrative Code may be utilized.

Last updated February 3, 2022 at 9:03 AM

Supplemental Information

Authorized By: 5162.05, 5164.02, 5167.02
Amplifies: 5164.02, 5164.03
Five Year Review Date: 2/3/2027
Prior Effective Dates: 12/31/2020