Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.18-017 - Amendment to Medicaid Patient-Centered Medical Home PCMH
Current through Register Vol. 49, No. 9, September, 2024
Section II Patient-Centered Medical Home
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Attributed beneficiaries |
The Medicaid beneficiaries for whom primary care physicians and participating practices have accountability under the PCMH program. A primary care physician's attributed beneficiaries are determined by the ConnectCare Primary Care Case Management (PCCM) program. Attributed beneficiaries do not include dual eligible beneficiaries. |
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Attribution |
The methodology by which Medicaid determines beneficiaries for whom a participating practice may receive practice support and incentive payments. |
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Care coordination |
The ongoing work of engaging beneficiaries and organizing their care needs across providers and care settings. |
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Care coordination payment |
Quarterly payments made to participating practices to support care coordination services. Payment amount is calculated per attributed beneficiary, per month. |
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Default pool |
A pool of beneficiaries who are attributed to participating practices that do not meet the requirements in Section 233.000, part A or part B. |
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Medical neighborhood barriers |
Obstacles to the delivery of coordinated care that exist in areas of the health system external to PCMH. |
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Participating practice |
A physician practice that is enrolled in the PCMH program, which must be one of the following: A. An individual primary care physician (Provider Type 01 or 03); B. A physician group of primary care providers who are affiliated, with a common group identification number (Provider Type 02, 04 or 81); C. A Rural Health Clinic (Provider Type 29) as defined in the Rural Health Clinic Provider Manual Section 201.000; or D. An Area Health Education Center (Provider type 69). |
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Patient-Centered Medical Home (PCMH) |
A team-based care delivery model led by Primary Care Physicians (PCPs) who comprehensively manage beneficiaries' health needs with an emphasis on health care value. |
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Performance-based incentive payments |
Performance-based incentive payments are payments made to a shared performance entity for delivery of economic, efficient and quality care |
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Performance adjustment |
An adjustment to the cost of beneficiary care to account for patient risk. |
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Performance period |
The period of time over which performance is aggregated and assessed. |
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Petite pool |
Pool reserved for practices with less than 300 attributed beneficiaries that do not wish to participate in a voluntary pool. |
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Pool |
A. The beneficiaries who are attributed to one or more participating practice(s) for the purpose of forming a shared performance entity; or B. The action of aggregating beneficiaries for the purposes of performance-based incentive payment calculations (i.e., the action of forming a shared performance entity). |
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Practice support |
Support provided by Medicaid in the form of care coordination payments to a participating practice. |
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Practice transformation |
The adoption, implementation and maintenance of approaches, activities, capabilities and tools that enable a participating practice to serve as a PCMH. |
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Primary Care Physician (PCP) |
See Section 171.000 of the Arkansas Medicaid provider manual. |
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Provider portal |
The website that participating practices use for purposes of enrollment, reporting to the Division of Medical Services (DMS) and receiving information from DMS. |
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Quality Improvement Plan (QIP) |
QIP is a plan of improvement that practices must submit to PCMH Quality Assurance team after receiving notice of attestation failure or validation failure. |
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Recover |
To deduct an amount from a participating practice's future Medicaid receivables, including without limitation, PCMH payments, or fee-for-service reimbursements, to recoup such amount through legal process, or both. |
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Remediation time |
The period during which participating practices that fail to meet deadlines, targets or both on relevant activities and metrics tracked for practice support may continue to receive care coordination payments while improving performance. |
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Same-day appointment request |
A beneficiary request to be seen by a clinician within 24 hours. |
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Shared performance entity |
A PCMH or pooled PCMHs that, contingent on performance, may receive performance-based incentive payments. |
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State Health Alliance for Records Exchange (SHARE) |
The Arkansas Health Information Exchange. For more information, qo to http://ohit.arkansas.qov. |
Enrollment is open for approximately six (6) weeks in Quarter 3 and Quarter 4 of the preceding calendar year.
DMS will not accept any enrollment documents received other than during an enrollment period.
Pooling is effective for a single performance period and must be renewed for each subsequent year.
When a PCMH has voluntarily pooled, its performance is measured in the associated shared performance entity throughout the duration of the performance period unless it withdraws from the PCMH program during the performance period. When a PCMH in a voluntary pool withdraws, is suspended, or otherwise leaves the PCMH program, any and all PCMHs in the shared performance entity will have their performance measured as if the withdrawn or suspended PCMH had never participated in the pool. This provision does not apply to PCMHs that leave the program in the last calendar quarter. If the PCMH leaves the program in the last calendar quarter, the departing PCMH, and its performance will be treated as if the PCMH has not left the program.
Each year, a Practice's performance in emergency department rates and inpatient rates will be measured and ranked. Shared performance entities that achieve the top 35th percentile of performance in the measures will be eligible to receive PBIP.
Certain conditions are excluded from the calculation of emergency room and inpatient rates. Each year, DMS will announce which exclusions it has applied on the API I website at http://www.paymentinitiative.org/pcmh-manual-and-additional-resources.
Each year, DMS will select a focus measure to improve quality and provide incentive to shared performance entities. The focus measure will focus on an area for which Arkansas ranks much lower than the national average. Shared performance entities that are ranked in the top 35th percentile of the focus measure will be eligible to receive PBIP.
Each year, DMS will announce which area has been selected as a
focus measure on the API I website at
Each year, DMS will announce which area has been selected as a
focus measure on the API I website at
A shared performance entity is eligible to receive performance-based incentive payments in one of the following ways:
Performance-based incentive payments will be calculated by multiplying the incentive amount by the number of member months attributed to each PCMH. PCMHs are eligible to receive incentive payments for either ranking in the top 10th or top 35th percentile for each measure. Measures are independent of one another, and practices are not required to achieve the same ranking across all measures to qualify for incentive bonus payments.
If participating practices have pooled their attributed beneficiaries together, then performance-based incentive payments will be allocated to those practices based on risk-and time-adjustment and in proportion to the number of attributed beneficiaries that each PCMH contributed to such pool.
Practice support is care coordination payments made to a PCMH to support the practices' transformations.
Receipt and use of the care coordination payments is not conditioned on the PCMH engaging a care coordination vendor, as payment can be used to support participating practices' investments (e.g., time and energy) in enacting changes to achieve PCMH goals. Care coordination payments are risk-adjusted to account for the varying levels of care coordination services needed for beneficiaries with different risk profiles.
DMS may pay, recover or offset overpayment or underpayment of care coordination payments.
DMS will also support PCMHs through improved access to information through the reports described in Section 244.000.
In addition to the enrollment eligibility requirements listed in Section 211.000, in order for PCMHs to receive practice support, DMS measures PCMH performance against activities tracked for practice support identified in Section 241.000. PCMHs must meet the requirements of this section to receive practice support.
Each PCMH in a shared performance entity will, if individually qualified, receive practice support even if another PCMH in a shared performance entity does not qualify for practice support.
Performance-based incentive payments are payments made to a shared performance entity for delivery of economic, efficient and quality care that meets the requirements in Section 232.000.
To receive performance-based incentive payments, a shared performance entity must have a minimum of 1,000 attributed beneficiaries once the exclusions listed below have been applied. A shared performance entity may meet this requirement as a single PCMH or by pooling attributed beneficiaries across more than one PCMH as described in Section 233.000.
DMS may add, remove or adjust these exclusions based on new
research, empirical evidence, provider experience with select beneficiary
populations or inclusion of new payers. DMS will publish such an addition,
removal or modification on the APII website at
Performance-based incentive payments are made to the individual PCMHs which are part of a shared performance entity. These payments are risk- and time- adjusted and prorated based on the number of beneficiaries of each PCMH. These payments are predicated on each PCMH maintaining eligibility for practice support as described in Section 222.000.
Shared performance entities will meet the minimum pool size of 1,000 attributed beneficiaries as described in Section 232.000 in one of four ways:
A shared performance entity's pool configuration (A, B, C, or D) is established during the enrollment period and cannot be changed after the end of the enrollment period.
PCMHs may voluntarily pool for purposes described in Section 233.000 before the end of the enrollment period that precedes the start of the performance period. To pool, the participating practice must email a complete and accurate Arkansas Medicaid Patient-Centered Medical Home Program Pooling Request Form (DMS-845) to ARKPCMH(5)DXC.com. View or print the Arkansas Medicaid Patient-Centered Medical Home Program Pooling Request Form on the API I website at http://www.paymentinitiative.org/pcmh-manual-and-additional-resources. You can also download the form from the AHIN provider portal.
The DMS-845 Pooling form must be executed by all PCMHs participating in the pool. Before the end of the enrollment period, PCMHs that are on their own or through pooling do not reach a minimum of 1,000 attributed beneficiaries will be assigned to the default pool. Practices with less than 300 attributed beneficiaries that do not wish to participate in a voluntary pool will be placed in the petite pool. Individual PCMHs whose attribution changes during the performance period will be classified as standalone, default, or petite pool members according to their attribution count at the end of the performance period.
Using the provider portal, participating PCMHs must complete
and document the activities as announced by DMS on the API I website at
In addition to activities tracked for practice support, DMS
will assess a practice's low performance of core metrics. The selected core
metrics will be announced at
Each year a Core Metric will be chosen to have its Minimal Performance assessed. For example, in 2019 the Core Metric may be infant wellness. A PCMH will be placed in remediation for the Infant Wellness Metric if 15% or greater of the patient panel (0-15 months), have 0-1 wellness visits and the PCMH does not meet the 2019 Quality Metric Target for 5 or more wellness visits.
Failure to meet the targets will result in a Notice of Failure to Meet Wellness Metrics Tracked for Practice Support. PCMHs which receive this notice will be subject to completion of a Quality Improvement Plan (QIP) and a 90-day remediation period. The PCMH will have 15 calendar days to submit a sufficient QIP. Failure to submit a sufficient QIP within 15 calendar days of receiving the notice will result in suspension of practice support. PCMHs which receive a notice will have 90 calendar days, from the date of the notice, to remediate performance of the metric. Successful completion of remediation will be determined by DMS based on the metric results reported in the monthly PCMH report, posted in the AHIN portal, the following month after remediation ends. If a PCMH fails to meet the deadlines or targets for the wellness metrics tracked for practice support within the specified remediation time, then DMS will suspend practice support.
DMS assesses quality metrics tracked for performance-based
incentive payments according to the targets announced by DMS at
www.paymentinitiative.org.
To receive a performance-based incentive payment, the shared performance
entity or PCMH must meet the quality metrics by which the entity or PCMH is
assessed and published on the API I website at
DMS provides participating PCMH provider reports containing information about their PCMH performance on activities tracked for practice support, quality metrics tracked for performance-based incentive payments and their utilization rates via the provider portal.
Failing to submit any updated license, address changes or changes to the Provider Id number, may result in provider reports with no beneficiary attribution. Providers may update at any time their licenses, address changes, or changes to their Provider ID number by submitting documentation to the Provider Enrollment unit via fax at (501) 374-0746. Providers who have concerns about information included in their reports should send an email to PCMH@AFMC.org. The PCMH Quality Assurance Manager will respond to the provider/practice with a review of their inquiry. If the review leads to a discovery that the provider report is inaccurate or does not reflect actual performance, DMS will take the necessary steps to correct the inaccuracies including those that are a result of a systems and/or algorithm error. Providers can also call the APII help desk at 501-301-8311 or 866-322-4698 and bv email at ARKPII@DXC.com.
Appeals
If you disagree with DMS' decision regarding program participation, payment or other adverse action, you have the right to request reconsideration and you have the right to request an administrative appeal. During the remediation period, and prior to the notice of adverse action, practices continue receiving practice support payments. However, DMS will not pay practice support payments after the notice of adverse action. If the practice prevails during the appeal, or reconsideration, the practice support payments will resume retroactively from the date of the adverse action notice.
The Department of Human Services must receive written request for reconsideration within (30) calendar days of the date of the adverse action, notice. Send your request to the Arkansas Department of Human Services, Division of Medical Services, Health Care Innovation: Attention PCMH - Reconsideration, P.O. Box 1437, Slot S425, Little Rock, AR 72203.
The Arkansas Department of Health must receive a written appeals request within (30) calendar days of the date of the adverse action notice, or within (10) calendar days of receiving a reconsideration decision. Send your request to Arkansas Department of Health: Attention: Medicaid Provider Appeals Office, 4815 West Markham Street, Slot 31, Little Rock, AR 72205.
