Chapter 5160-19 | Patient-Centered Medical Homes

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

• Effective: December 12, 2024
• 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 primary care practitioners (PCPs) who are able to participate in the medicaid program in accordance with rule 5160-1-17.2 of the Administrative Code. The Ohio department of medicaid (ODM) is responsible for attributing fee-for-service recipients; medicaid managed care organizations (MCOs) are responsible for attributing their enrolled recipients. 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 CPC and CPC for kids program:

(a) The recipient's choice of provider.

(b) Claims data concerning the recipient.

(c) Other data concerning the recipient.

(2) "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."

(3) "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 ODM or the MCOs. All medicaid recipients are attributed. The following attributed individuals are excluded from CPC program quality and efficiency metrics, total cost of care calculations, and per member per month payments:

(a) Recipients dually enrolled in both medicare and Ohio medicaid.

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

(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 third party 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, 2023), under contract with ODM.

(e) Recipients attributed to other population health alternative payment models administered by ODM under Chapter 5160-19 of the Administrative Code.

(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 PCPs who comprehensively manage the health needs of individuals. Provider enrollment in ODM's PCMH program, known as the 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.

(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.

(g) Geriatric.

(2) Clinical nurse specialist, certified nurse midwife, 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.

(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 attest that it will share all requested 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.

(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 CPC entity 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) Provide twenty-four-seven and same-day access to a PCP with access to the attributed medicaid individual's medical record.

(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 MCOs 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 PCP 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 six 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 thirty 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.

(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 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.

(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) Chlamydia screening for women.

(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.

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

(21) Well visits for members who are fifteen to thirty months 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.

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

(9) Well visits for members who are fifteen to thirty months of age.

(10) Oral evaluation, dental services.

(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.

(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 December 12, 2024 at 8:14 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 10/17/2025

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

• Effective: December 12, 2024
• 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. Further detail regarding risk-adjustment can be found on the Ohio department of medicaid (ODM) website, www.medicaid.ohio.gov.

(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 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 except for those excluded in rule 5160-19-01 of the Administrative Code.

(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 to reward total cost of care savings.

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

(i) The CPC entity has to meet quality, efficiency, and financial outcomes outlined in rule 5160-19-01 of the Administrative Code;

(ii) The CPC entity has at least sixty thousand member months in the performance period;

(iii) The CPC entity achieves savings on its total cost of care during the performance period compared to its own baseline total cost of care performance 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. Baseline total cost of care calculations may be adjusted mid-performance year as necessary to reflect factors such as population acuity shifts. 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.

(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 is determined by the CPC entity's total cost of care for its attributed medicaid individuals as defined in rule 5160-19-01 of the Administrative Code.

(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. More information on the CPC for kids program 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.

(v) Oral evaluation, dental services.

(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 percent 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 percent. If additional ties persist then.

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

(D) Payment and program participation 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, program participation and payment under this rule terminates.

(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 in a program year, a warning will be issued. After two consecutive program years of a metric not being met, entity participation in the program and 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 program years of a metric not being met, the CPC for kids entity participation in the program and 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 December 12, 2024 at 8:14 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 10/17/2025
Prior Effective Dates: 10/17/2020, 11/9/2023

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

• Effective: December 12, 2024
• 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 women 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 women 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 women.

(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 women 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 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 that an e-PRAF is submitted for every pregnant woman.

(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 women will be assigned to either of the following risk tiers:

(a) Pregnant or postpartum women who:

(i) 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;

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

(iii) 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 women 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 patient's 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 women 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 individual's 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 women 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 individual's 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.

(d) Allow patients to have a doula of their choice at any pregnancy related service or appointment. Patients that procure or request the assistance of a doula as part of their prenatal, birth, or postpartum care will be supported by the practice in receiving doula services, including by providing a written recommendation for doula services to patients upon request.

(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.

(7) Maternal behavioral health screenings (i.e., depression, anxiety, subtance use disorder, etc.)

(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 in a program year, a warning will be issued. After two consecutive program years of a metric not being met, 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 December 12, 2024 at 8:14 AM

Supplemental Information

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