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This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and universities.

Chapter 5160-19 | Patient-Centered Medical Homes

 
 
 
Rule
Rule 5160-19-01 | Patient-centered medical homes (PCMH): eligible providers.
 

(A) 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 PCMH may be a single practice or a practice partnership.

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

(1) "Attributed medicaid individuals" are Ohio medicaid recipients for whom PCPs have accountability under a PCMH. A PCP's attributed medicaid individuals are determined by 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 dental or vision coverage.

(2) "Attribution" is the process through which medicaid recipients are assigned to specific PCPs. ODM is responsible for attributing fee-for-service recipients; MCOs are responsible for attributing their enrolled recipients. The following hierarchy will be used in assigning recipients to PCPs under the PCMH and PCMH for kids program:

(a) The recipient's choice of provider.

(b) Claims data concerning the recipient.

(c) Other data concerning the recipient.

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

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

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

(6) "Practice Partnership" is a group of practices participating as a PCMH 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 PCMH 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.

(C) The following eligible providers may participate in ODM's PCMH program through their contracts with MCOs or provider agreements for participation in medicaid fee-for-service:

(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.

(D) The following eligible providers may participate in the delivery of primary care activities or services in the PCMH 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.

(E) To be eligible for enrollment in the PCMH program for payment beginning in 2021, the PCMH 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;

(F) To be eligible for enrollment in the PCMH for kids program for payment beginning in 2021, the PCMH will:

(1) Be a PCMH that participated in ODM's PCMH program for the 2020 program year; and

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

(G) It is the responsibility of an enrolled PCMH 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 PCMH 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 PCMH 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 PCMH 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 indivudual.

(4) Complete the "team-based care delivery" activities in which the PCMH 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 PCMH.

(5) Complete the "care management plans" activities in which the PCMH will create care plans that include necessary elements for all high-risk attributed medicaid individuals as identified by the PCMH's risk stratification process.

(6) Complete the "follow-up after hospital discharge" activities in which the PCMH 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 PCMH 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 PCMH 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 PCMH 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 PCMH practice 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 PCMH practice 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.

(H) Except for the 2020 calendar year, it is the responsibility of a PCMH practice 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) Referral patterns to episode principle accountable providers (PAPs) as defined in agency 5160 of the Administrative Code.

(I) Except for the 2020 calendar year, it is the responsibility of a PCMH practice 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) Well-child visits in the third, fourth, fifth, and sixth years of life;

(3) Adolescent well-care visit;

(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) Adult BMI;

(11) Controlling high blood pressure;

(12) Medical management of attributed medicaid individuals with asthma;

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

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

(15) Comprehensive diabetes care: HbA1c testing;

(16) Comprehensive diabetes care: eye exam;

(17) Antidepressant medication management;

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

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

(20) Initiation and engagement of alcohol and other drug dependence treatment.

(J) Except for the 2020 calendar year, it is the responsibility of a PCMH practice participating in PCMH 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) Well-child visits in the third, fourth, fifth, and sixth years of life;

(6) Adolescent well-care visit; and

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

(K) Except for the 2020 calendar year, it is the responsibility of a PCMH practice participating in PCMH 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.

(L) A PCMH 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 PCMH or PCMH for kids enrollment or eligibility.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 10/17/2025
Rule 5160-19-02 | Patient centered medical homes (PCMH): payments.
 

(A) A patient centered medical home (PCMH) has to be enrolled and meet the provisions set forth in rule 5160-19-01 of the Administrative Code to be eligible for PCMH payments.

(B) A PCMH participating in the PCMH for kids program has to be enrolled as a PCMH and meet all provisions set forth in rule 5160-19-01 of the Administrative Code to be eligible for PCMH for kids payments.

(C) An eligible PCMH may qualify for the following payments:

(1) The "PCMH per-member-per-month (PMPM)" is a payment to support the PCMH.

(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 ODM;

(2) The "PCMH for kids enhanced per-member-per-month (PMPM)" is a payment to support the PCMHs participating in the PCMH for kids program.

(a) Payment is in the form of a prospective flat PMPM payment per attributed medicaid pediatric individual;

(b) Payment begins following PCMH enrollment in PCMH for kids and in accordance with the payment schedule determined by ODM.

(3) The "PCMH shared savings payment" is a payment for a PCMH that meets quality, efficiency, and financial outcomes. PCMH practices are not eligible to earn this payment for the 2020 calendar year as they are not subject to the quality and efficiency metric thresholds.

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

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

(ii) The PCMH 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 PCMH practices based on total cost of care performance. The total cost of care for a PCMH is calculated by summing all claims for a given patient, plus any PMPM payment that the PCMH has received through the PCMH 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 PCMH 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 paragraph (B)(1) of rule 5160-19-01 of the Administrative Code; and

(ii) An annual retrospective bonus payment based on total cost of care for PCMHs in the top-performing decile, to be determined annually by ODM and not to exceed one million dollars.

(4) The "PCMH for kids bonus payment" is an annual retrospective payment for the highest performing PCMHs participating in the PCMH for kids program that meet quality and efficiency outcomes and perform additional bonus activities focused on improving pediatric care. PCMH practices are not eligible to earn this payment for the 2020 calendar year as they are not subject to the quality and efficiency metric thresholds identified in rule 5160-19-01 of the Administrative Code.

(a) To be eligible for the PCMH for kids bonus payment other than for calendar year 2020, the PCMH has to be a high performing PCMH relative to other PCMHs participating in the PCMH 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 foster care;

(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 PCMH 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 PCMHs 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 PCMH in the tie group.

(D) Payment conditions.

(1) A PCMH has to continue completing activities annually as defined in paragraph (G) of rule 5160-19-01 of the Administrative Code. If activities are not completed upon evaluation, payment under this rule terminates; and

(2) Except for the 2020 calendar year, t PCMH has to continue to meet efficiency and clinical quality metrics defined in paragraphs (H) and (I) of 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) Except for the 2020 calendar year, a PCMH participating in PCMH for kids has to continue to meet clinical quality metrics defined in paragraphs (J) and (K) of 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, PCMH for kids payments under this rule will be terminated.

(E) A PCMH 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.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 10/17/2025
Rule 5160-19-04 | Episode based payments.
 

(A) Excluding calendar years 2020 and 2021, 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 and 2021.

(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 and 2021.

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.

Supplemental Information

Authorized By: 5162.05, 5164.02, 5167.02
Amplifies: 5164.02, 5164.03
Five Year Review Date: 12/31/2020