Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL)
Chapter VI
Section 144-101-VI-03 - Primary Care Plus
Subsection 144-101-VI-0308 - REIMBURSEMENT

Universal Citation: 144-101-VI-03 ME Code Rules ยง 144-101-VI-0308

Current through 2024-38, September 18, 2024

3.08-1 Population-Based Payment

Population-Based Payments (PBPs) are monthly payments that the Department shall calculate quarterly for each participating PCP. The Department calculates the PBP by adding the Tier PMPM Rate and the Population Group and Risk Category PMPM Rate and multiplying the sum by the PCP's total number of attributed Members. Both PMPM rates are determined annually.

A. Tier PMPM Rate This PMPM rate is determined by the provider's Tier, and the Department adjusts this PMPM rate by the Performance-Based Adjustment (PBA) when calculating the PBP, per Section 3.08-2. Each Tier described in Section 3.03 has a PMPM rate:

Tier One: $2.10

Tier Two: $6.30

Tier Three: $6.90

B. Population Group and Risk Category PMPM Rate Annually, the Department will assign Members to a population group based on their eligibility category in the most recent month of the PBA Assessment Period and a risk category based on the most recent Risk Score. The population groups are children, adults, aged/blind/disabled, and dual-eligible. The risk categories are "generally well" and "complex." Each combination of population group and risk category has a PMPM rate (see Figure 1). The Department calculates the overall PMPM rate by multiplying the number of Members the PCP has in each combination of population group and risk category by the assigned PMPM rate. The Department then adds the totals from each combination and divides by the PCP's number of Members.

Providers may request a reassessment of their Population Group and Risk Category PMPM if there is a significant change within the practice, such as a relocation or inclusion of a new population.

Figure 1. Population group and risk category PMPM rates

Population Group

Risk Category

Generally Well PMPM

Complex PMPM

Children

$1.65

$4.95

Adults

$1.15

$3.00

Aged, Blind, Disabled

$2.25

$6.60

Duals

$2.50

$8.75

3.08-2 Performance-Based Adjustment

The PBA is based on a PCP's performance on no more than ten (10) quality measures. Current quality measures will be listed on: https://www.maine.gov/dhhs/oms/providers/value-based-purchasing. The PBA may range from negative ten percent (-10%) to twenty five percent (25%) and is applied quarterly to the Tier PMPM rate.

For the first year of the PCPlus program, the Department will apply a PBA of 25% to Tier One PCPs, 8.3% to Tier Two PCPs, and 7.6% to Tier Three PCPs. Performance data will be shared for information only during this time.

Beginning one (1) year after the effective date of the PCPlus rule, the Department will calculate and apply the PBA, as described herein.

A. Calculation of PBA. The PBA equals the sum of the quality measures' Improvement and Achievement Adjustments (see subparts 3 and 4), which are based on a PCP's Percentile Score (see subpart 1) for each quality measure and each quality measure's domain (see subpart 2).
1. Percentile Score.To calculate the Percentile Score, the Department first calculates the PCP's performance on each quality measure. Calculating performance varies for each measure. For example, performance on the Lead Testing in Children quality measure equals the percentage of Members two (2) years of age who had at least one capillary or venous lead blood test for lead poisoning by their second birthday.

The Department then compares the PCP's performance on each quality measure with the performance of the PCPs in its MaineCare Peer Group to determine its Percentile Score for each quality measure. A PCP's Percentile Score represents the percentage of PCPs that performed below the PCP, e.g. a PCP with a Percentile Score of 65% performed better than 65% of the PCPs in its MaineCare Peer Group.

2. Domain. Each quality measure falls under either the Utilization or Comprehensive Care domain. For example, Acute Hospital Utilization falls under the Utilization domain, and Developmental Screening in the First Three Years of Life and Total Cost of Care fall under the Comprehensive Care domain. Each domain has a unique set of Improvement and Achievement Adjustment percentages that apply to the quality measures that fall under each domain (see Figure 2). The total minimum and maximum adjustment amounts from the quality measure(s) under the Utilization and Comprehensive Care domains are 30% and 70%, respectively, of the minimum and maximum PBA.

3. Improvement Adjustment. The Department will determine Improvement Adjustments by comparing the PCP's Percentile Score for each quality measure in the most recent PBA Assessment Period to the PCP's Percentile Score in the calendar year that falls two (2) years prior to the end date of the current PBA Assessment Period, e.g. a PBA Assessment Period ending July 2023 would be compared to calendar year 2021.

A PCP's Percentile Score must improve by at least three percentage points, regardless of whether the PCP's MaineCare Peer Group is different than its MaineCare Peer Group in the comparison year, to be eligible for the Improvement Adjustment, e.g. a PCP with a Percentile Score of 65% in the comparison year would have to achieve a Percentile Score of at least 68% in the Assessment Period to obtain the Improvement Adjustment for a quality measure (see Figure 2).

4. Achievement Adjustment. The Department will determine Achievement Adjustments for each quality measure based on Percentile Score (see Figure 2).
a. Through 2023, the Department will calculate Percentile Scores for the Achievement Adjustments by comparing the PCP's performance to its MaineCare Peer Group's performance from the most recent PBA Assessment Period.

b. Beginning in 2024, the Department will calculate Percentile Scores for the Achievement Adjustments by comparing the PCP's performance from the most recent PBA Assessment Period to the performance of its MaineCare Peer Group in the calendar year that falls two (2) years prior to the end date of the current Assessment Period.

5. Methodology Illustration. To illustrate the methodology using Figure 2, a PCP with a Percentile Score between 60% and 69% for the Acute Hospital Utilization quality measure would receive an Achievement Adjustment of 1.5%. If the PCP's Percentile Score improved by at least 3% from the comparison year, it would also earn the 1.3% Improvement Adjustment. If the PCP earned a Percentile Score between 50% and 59% for the Total Cost of Care quality measure, it would receive a 0.3% Achievement Adjustment. If the PCP's Percentile Score did not improve by at least 3% from the comparison year, it would not earn the 0.1% Improvement Adjustment. This assessment is done for each quality measure, and the PBA equals the sum of the Achievement and Improvement Adjustments.

Figure 2. Achievement and Improvement Adjustments* under the Utilization and Comprehensive Care domains, adapted from the Centers for Medicare and Medicaid Innovation, Primary Care First methodology.

Percentile Scores Relative to Peer Group

Utilization

Comprehensive Care

Achievement adjustment (%)

Improvement adjustment (if earned) (%)

Achievement adjustment (%)

Improvement adjustment (if earned) (%)

<25

-3.0

2.5

-0.9

0.8

25-49

0

0.5

0

0.2

50-59

.8

0.7

0.3

0.1

60-69

1.5

1.3

0.4

0.4

70-79

3.5

1.0

1.0

0.3

80-89

5.0

0.9

1.5

0.2

>90

7.0

0.5

2.1

0.1

*The adjustment percentages in Figure 2 are based on using nine (9) quality measures, one (1) under the Utilization domain and eight (8) under the Comprehensive Care domain. If more or fewer quality measures are used, the Department will change the adjustment percentages proportionally so the PBA range remains between negative ten (-10) and 25% and so the total minimum and maximum adjustment amounts from the quality measure(s) under the Utilization and Comprehensive Care domains remains 30% and 70%, respectively, of the minimum and maximum PBA.

B. The Department shall use the rolling twelve- (12) month PBA Assessment Period to collect claims data for the PBA and apply the PBA six (6) months after the Assessment Period ends to allow for three (3) months of claims run out and three (3) months to calculate the PBA.

C. A quality measure will only be used to assess performance if there is a sufficient quality measure-eligible population to allow for appropriate assessment. The sufficient quality measure-eligible population for each quality measure will be listed on: https://www.maine.gov/dhhs/oms/providers/value-based-purchasing. If a quality measure cannot be included in the performance assessment because of an insufficient quality measure-eligible population, the respective portion of the PBA for that quality measure will be redistributed equally among all other qualifying quality measures within the same domain.

D. PCPs must have sufficient Members on at least one (1) quality measure in the Utilization domain and at least three (3) quality measures in the Comprehensive Care domain to be eligible for each quality measure's adjustments within their domain. If a PCP does not meet the minimum quality measure requirement for a domain, they shall receive a neutral PBA (zero percent (0%)) for that domain.

E. The Department will notify PCPs at least one hundred twenty (120) days prior to any changes to the quality measures. The Department will provide PCPs quarterly reports on performance on quality measures, beginning no later than the second quarter of PCPlus program implementation.

Disclaimer: These regulations may not be the most recent version. Maine may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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