CPC+ Overview

  • Comprehensive Primary Care Plus (CPC+)   is an advanced primary care medical home model that rewards value and quality through innovative payments that support comprehensive care.
  • An initiative developed by CMS that transitions Medicare fee-for-service to value-based payments in collaboration with Medicaid and commercial payers in selected regions.
  • Montana was   1 of only 14 regions   selected across the country to participate with Medicare in this exciting 5-year test demonstration that will support primary care in our state. (7 additional payers in four regions were selected for CPC+ Round 2, beginning in 2018.)
  • Blue Cross Blue Shield of Montana, PacificSource, and Allegiance Life and Health have also partnered with Medicaid and Medicare in this model.CPC+ payer partners and providers are collaborating around the goals of smarter healthcare spending, more effective healthcare delivery, and healthier patients.
  • The CPC+ advanced primary care medical home model is centered on   five key functions:
    • Access and Continuity;
    • Care Management;
    • Comprehensiveness and Coordination;
    • Patient and Caregiver Engagement; and
    • Planned Care and Population Health.
  • The program includes Track 1 and Track 2 practices.
  • Track 2 practices also receive alternative FFS payments starting in 2018 that they are required to use for non-traditional face-to-face visits.

Background of Montana’s CPC+ Participation

  • In August 2016, CMS chose Montana as a region to participate based on strong payer collaboration established through the Governor’s Healthcare Innovation Council and the Montana Patient-Centered Medical Home (PCMH) Program.
  • Montana primary care practices applied to CMS in September and 56 selected practices were announced in late November 2016.

Helpful Links:

Montana Medicaid’s CPC+ Program

Effects  on Existing Medicaid Programs:

  • Waivers:   CPC+ care management will not replace or interfere with the case management provided to members in the waiver programs: SDMI, Autism (667), DDP 0208 (DD Comprehensive Waiver), Big Sky Waiver (SLTC Waiver).
  • Patient-Centered Medical Home (PCMH):  Clinics cannot be both a PCMH and CPC+; they have to choose one program.  Medicaid’s PCMH program will continue separately, adjust to align with CPC+.
  • Passport to Health and Team Care: Providers with members in Passport or Team Care must still follow all the same program rules and the members will still receive the program benefits but the CPC+ payments will replace the capitation payments for these programs.

Medicaid CPC+ Payment Plan:

  • Medicaid pays providers monthly care management fees (PMPM) based on members’ risk tier assignment.
  • Medicaid members are assigned a risk score through Medicaid’s predictive modeling risk software and divided into tiers based on their score of potential risk across the entire population.
  • Medicaid will retrospectively pay CPC+ practices annual performance-based incentive payments, based on a combination of utilization (i.e. ER visits and hospitalizations) measures and quality measures (i.e. A1C and blood pressure control).
  • Providers will be paid a quality bonus retrospectively at the end of the quality of care and utilization measurement period annually.
  • The amount will be based on the practice’s level of meeting the performance benchmarks, based on national standards and regional alignment with other payers.
  • Practices that meet quality and utilization thresholds will be rewarded with per member per year (PMPY) payments.
  • Track 2 Alternative Payment Method:
    • Payment under the Medicaid Physician Fee Schedule: Medicaid will pay alternative payments to Track 2 CPC+ practices using a partial Comprehensive Primary Care Payment (CPCP) that will be an up-front lump sum, replacing part of the expected fee-for-service payments for the coming year.
    • The Comprehensive Primary Care Payment (CPCP) will be calculated based on historical Evaluation and Management (E&M) services for attributed patients at the practice.
    • The calculation will look back two (2) historical years on total paid claims for E&M services only, for attributed patients at the Track 2 CPC+ Practice.
    • Alternative Payment Method to Track 2 practices to begin approximately July 1 st, pending CMS approval:
Payment Method 2017 2018 2019 2020 2021
FFS% 100% 90% 90% 60% 60%
CPCP%- up front 0% 10% 10% 40% 40%
  • Track 2 CPC+ practices must offer at least one alternative type of access to the patient’s care team in ways that best meet the needs of the Medicaid population.  Alternative types of visits include:
    • e-visits;
    • phone visits;
    • group visits;
    • alternate location visits (i.e. community center, library, etc.);
    • expanded hours in early mornings, evenings, and weekends.