Additional Payment Available for Meeting Enhanced Primary Care Medical Provider Standards

Primary Care Medical Providers within the Accountable Care Collaborative (ACC) are now eligible to receive an additional $0.50 Per Member Per Month (PMPM) payment for providing enhanced primary care services to their ACC members.

To be eligible for the additional payment, PCMPs must meet at least five (5) of the nine (9) following Enhanced Primary Care Factors:

(1) The PCMP has regularly scheduled appointments (at least one time per month) on a weekend and/or on a weekday outside of typical workday hours.

(2) The PCMP provides timely clinical advice by telephone or secure electronic message both during and after office hours. Members and families are clearly informed about these procedures.

(3) The PCMP uses available data (e.g., SDAC, clinical information) to identify special patient populations who may require extra services and support for medical and/or social reasons. The Practice has procedures to proactively address the identified health needs.

(4) The PCMP provides on-site access to behavioral health care providers.

(5) The PCMP collects and regularly updates a behavioral health screening (including substance use) for adults and adolescents and/or developmental screening for children (newborn to five years of age) using a Medicaid-approved tool. In addition, the practice has documented procedures to address positive screens and has established relationships with providers to accept referred patients or utilize the standard referral and release form created by the Behavioral Health Organizations.

(6) The PCMP generates lists of members actively receiving care coordination.

(7) The PCMP tracks the status of referrals to specialty care providers and provides the clinical reason for the referral along with member clinical information.

(8) The PCMP will accept new Medicaid members for the majority of the year.

(9) The PCMP and member/family/caregiver collaborate to develop and update an individual care plan.

Important Details:

  • Regional Care Collaborative Organizations (RCCOs) are responsible for certifying practices within their region that meet the criteria.
  • The additional payment is $0.50 Per Member Per Month (PMPM) and will be received in an annual lump sum payment.
  • Approval for this program can be backdated to July 1, 2014 with appropriate documentation, so that practices can receive the Per Member Per Month payments for this fiscal year, if eligible.
  • Payment will occur following the close of the fiscal year (July 2014 - June 2015).
  • A detailed description of the nine (9) Enhanced Primary Care Factors can be downloaded in PDF format

Please contact Nicole Konkoly at nicole.konkoly@rmhp.org or (303) 967-2004 for additional information or to initiate the certification process.