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Comprehensive Primary Care Plus (CPC+)

CPC+ Consulting in Hackensack, New Jersey

Overview

CMS Comprehensive Primary Care Plus (CPC+) is a national advanced primary care medical home model created to make primary care better through a five-year, multi-payer payment reform delivery transformation.

CPC+ includes two tracks – for practices building capabilities and for those already delivering advanced primary care – with advanced care delivery requirements and payment options to meet the diverse needs of primary care practices.

Participants

Arkansas: Statewide
Arkansas Blue Cross and Blue Shield, Arkansas Superior Select, Arkansas Health & Wellness Solutions, HealthSCOPE Benefits, Medicaid, QualChoice Health Plan Services, Inc.

Colorado: Statewide
Anthem Blue Cross and Blue Shield, Colorado Choice Health Plans, Medicaid, Rocky Mountain Health Plans, UnitedHealthcare

Hawaii: Statewide
Hawaii Medical Service Association

Greater Kansas City: Johnson County, KS; Wyandotte County, KS; Clay County, MO; Jackson County, MO; Platte County, MO
BlueCross BlueShield of Kansas City, UnitedHealthcare

Michigan: Statewide
BlueCross BlueShield of Michigan, BlueCross BlueShield of Michigan, Priority Health

Montana: Statewide
BlueCross BlueShield of Montana, Montana Medicaid, PacificSource Health Plans

New Jersey: Statewide
Amerigroup New Jersey, Inc., Delaware Valley ACO, Horizon BlueCross BlueShield of New Jersey, UnitedHealthcare

North Hudson-Capital Region (New York)
Capital District Physicians’ Health Plan, Empire BlueCross BlueShield, MVP Health Plan, Inc.

Ohio & Northern Kentucky: All counties in Ohio; Boone County, KY; Campbell County, KY; Grant County, KY; Kenton County, KY
Aetna, Anthem, Aultman Health Foundation, Buckeye Health Plan, CareSource, Gateway Health Plan of Ohio, Inc., Medical Mutual of Ohio, Molina Healthcare of Ohio, Inc., Ohio Medicaid, Paramount Health Care, SummaCare, Inc., The Health Plan, UnitedHealthcare

Oklahoma: Statewide
Advantage Medicare Plan, BlueCross BlueShield of Oklahoma, CommunityCare HMO, Inc., Oklahoma Medicaid, UnitedHealthcare

Oregon: Statewide
AllCare Health, Inc., ATRIO Health Plans, Inc., CareOregon, Eastern Oregon Coordinated Care Organization, FamilyCare Health, Moda Health Plan, Inc., Oregon Medicaid, PacificSource Health, PrimaryHealth of Josephine County, Providence Health Plan, Tuality Health Alliance, Western Oregon Advanced Health, Willamette Valley Community Health Organization, Yamhill Community Care Organization, Inc.

Pennsylvania: Greater Philadelphia Area
Aetna, Independence BlueCross/Keystone Health Plan East, Delaware Valley ACO

Rhode Island: Statewide
BlueCross BlueShield of Rhode Island, Rhode Island Medicaid, Tufts Health Plan, UnitedHealthcare

Tennessee: Statewide
Amerigroup Tennessee, Tennessee Medicaid, United Healthcare, Volunteer State Health Plan

Payment Structure

To support the delivery of comprehensive primary care, CPC+ includes three payment elements:

  1. Care Management Fee (CMF): Both tracks provide a non-visit-based CMF paid per-beneficiary-per month (PBPM). The amount is risk-adjusted for each practice to account for the intensity of care management services required for the practice’s specific population. The Medicare fee-for-service (FFS) CMFs will be paid to the practice on a quarterly basis.
  2. Performance-Based Incentive Payment: CPC+ will prospectively pay and retrospectively reconcile a performance-based incentive based on how well the practice performs on patient experience measures, clinical quality measures, and utilization measures that drive total cost of care.
  3. Payment under the Medicare Physician Fee Schedule: Track 1 continues to bill and receive payment from Medicare FFS as usual. Track 2 practices also continue to bill as usual, but the FFS payment will be reduced to account for CMS shifting a portion of Medicare FFS payments into Comprehensive Primary Care Payments (CPCP), which will be paid in a lump sum on a quarterly basis absent a claim. Given our expectations that Track 2 practices will increase the comprehensiveness of care delivered, the CPCP amounts will be larger than the FFS payment amounts they are intended to replace.

Care Management Fee (CMF)

CMS provides prospective monthly care management fees (CMFs) to Track 1 and 2 practices. As highlighted in the table below, the Medicare CMFs average $15 per-beneficiary per-month (PBPM) across 4 risk tiers in Track 1. In Track 2, the Medicare CMFs average $28 PBPM across 5 risk tiers, which include a $100 CMF to support care for Medicare beneficiaries with the most complex needs. Practices may use this enhanced, non-visit-based compensation to support augmented staffing and training needed to meet the model requirements according to the needs of their patient population.

Risk Tier Attribution Criteria Track 1 Track 2
Tier 1 1st quartile HCC $6 $9
Tier 2 2nd quartile HCC $8 $11
Tier 3 3rd quartile HCC $16 $19
Tier 4 4th quartile HCC for Track 1;
75-89% HCC for Track 2
$30 $33
Complex
(Track 2 only)
Top 10% HCC
OR
Dementia
N/A $100
Average PBPM $15 $28

CPC+ payer partners will also provide non-visit based financial supports to practices based on their own methods.

Track 2 Hybrid Payment

Medicare fee-for-service (FFS) payments will remain unchanged in Track 1. In Track 2, CMS is introducing a hybrid of FFS and Comprehensive Primary Care Payment (CPCP). This hybrid payment will pay for covered evaluation and management (E&M) services, but allows flexibility for the care to be delivered both in and out of an office visit. In an effort to recognize practice diversity in readiness for this change in payment, CMS will allow practices to move to one of these final two proposed hybrid payment options (40 percent or 65 percent CPCP with 60 percent or 35 percent FFS), at their preferred pace by 2021, pursuant to the options shown in this table:

CPCP and FFS Options

2017 2018 2019 2020 2021
Tier 1 10% / 90%
Tier 2 25% / 75% 25% / 75%
Tier 3 40% / 60% 40% / 60% 40% / 60% 40% / 60%
Tier 4 65% / 35% 65% / 35% 65% / 35% 65% / 35% 65% / 35%

**1st Column is the 10/90 approach with increments made quarterly, practices receive initially receive 10% or 11% of previous years E&M coding up front and 10% of the alternative means visits like phone, text, e-visit this is CPCP, this is only for 1,000 patients

** On average FFS per member for CMS averages $16.50 per member per month plus they get the PBPM average of $15 for Track 1 and $28 for Track 2

CPC+ Revenue Calculator

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Contact Information

277 Prospect AvenueHackensack, New Jersey

855-544-0475

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