(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.
ODM
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.
PCMH practices 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
PCMHCPC
CPC
and
PCMHCPC
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
.
"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
the Ohio department of medicaid (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 third party dental or 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, 2021), under contract with ODM.
(e) Recipients attributed to other
population health alternative payment models administered by ODM (e.g.,
comprehensive maternal care).
(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:
"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.
(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 (e.g., comprehensive maternal care).
(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
primary care practitioners (PCPs)
PCPs who comprehensively manage the health needs of
individuals. Provider enrollment in
the Ohio
department of medicaid (ODM)
ODM's PCMH
program, known as the
comprehensive primary care
(CPC)
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
; and
.
(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:
(c) General preventive medicine
;
.
(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:
(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
;
and
.
(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
PCMH
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) Within
twenty-four hours of initial request, provide access to a
primary care practitioner
PCP 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 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
managed care
organizations
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
primary
care provider
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 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 selfmanagement 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 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
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) 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
;
.
(8)
Breast cancer
screening;
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
; and
.
(20)
Well visits for members who are eighteen to twenty-one years 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
; and
.
(8) Well visits for members who are eighteen
to twenty-one years of age.
(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
; and
.
(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.