Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-19 - Patient-Centered Medical Homes
Section 5160-19-02 - Comprehensive primary care (CPC) program: payments

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

(ii) 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:

(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.

(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.

(i) The CPC entities are ranked based upon the highest average point performance over threshold across all applicable quality and efficiency metrics, rounded to the nearest per cent. If additional ties persist then.

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