Practice-level Implications of the State
Medicaid Rule to Allow for PCPCH
Enhanced Payment
ECHO Optional CallApril 26, 2012
Objectives
 By the end of this call, we hope you will be able to:
 Demonstrate an improved understanding about the
difference between PCPCH certification and rules
that apply in order to receive enhanced payment
 Demonstrate an improved understanding of the
implications of the Medicaid rule in order for a
practice to receive enhanced reimbursement
 Recognize important next steps in obtaining
Medicaid payments for ACA qualifying patients
Important Context:
Difference between Certification & Payment
 Within the OHA:
 OHPR oversees PCPCH Standards and Certification Process
 THEN, each payer has a set of rules/policies that allow them to provide
enhanced reimbursement by the tiers
 Medicaid (DMAP) is one of the payers
Therefore, DMAP has rules to allow them to pay
 Other payers down the road may have other rules
 E.g. Future groups may be PEBB, OEBB, Office of Private Health Partnerships

 Medicaid (DMAP) needed CMS approval for enhanced payments based
on PCPCH Designation
 Some of the funding is supported within the ACA, Section 2703 is the
legislation
 Therefore, some parts of the enhanced payment process are therefore INFLEXIBLE
because they were written into ACA by Congress
Activities over the last month
 DMAP submitted a Medicaid waiver amendment to allow for
enhanced payments
 CMS approval is needed; therefore certain practice-level
activities were required by CMS
 The rule reflects the compromise between DMAP-OHA and CMS
to ensure it met CMS expectations
 As part of CMS and Quality Review requirements, there will be
audits of compliance with the Medicaid Rule
 Currently, it sounds like this audit will happen by Medicaid at the
time that OHPR does its audits of PCPCH certification (This
mentioned in meetings, not listed publicly)
 This audit would involve medical chart reviews given the
documentation requirements
Review of the Medicaid Rule:
OPIP Review - Big Things to “Notice”
1.
2.
3.
4.
5.
ACA qualifying conditions
Six “core” services provision
Person-centered plan
PCPCH Team definition
Generation of patient list and Enhanced Payment


FFS: ACA and Non-ACA
MCO: ACA
5. Patient agreement to participate in PCPCH
6. Documentation requirements at the patient level
7. Panel management
ACA Qualified Patients
(Page 1 of Rule)
Defined as individuals with:
1) A serious mental health condition
2) A least two chronic conditions proposed by state and
approved by CMS
3) One chronic condition and at risk of another qualifying
conditions as described above
Serious Mental Health Conditions in ACA
ACA TOPIC I How State Operationalized
At-Risk:
Opportunities for Identifying Children
RELIES ON CLINICAL JUDGEMENT
EXAMPLE: As part of Bright Futures You Do

BMI Assessment:


At risk for overweight (NOT obese)
Family risk factor screening:

If parent smokes, at risk for asthma
At-Risk:
Opportunities for Identifying Children

Look closely at DX code for:



995.52 Child neglect (nutritional)
995.53 Child sexual abuse
995.54 Child physical abuse
Six Core Services
(Page 1-2)
Important to understand these services as quarterly provision of at
least one is required, documentation required:
1. Comprehensive care management
2. Care Coordination
3. Directly collaborating or co-managing clients with specialty
mental health/substance abuse/developmental disabilities and
long term care
4. Comprehensive transitional care
5. Individual and family support services
6. Referral to community and social support services
Six Core Services
Some things to notice:
1. Comprehensive care management


2.
Includes population panel management
That said, documentation needs to be chart of population panel
management (a grey area – see later re: Documentation)
Care Coordination

Strong emphasis on person-centered plan (later on required
separately)
3. Comprehensive transitional care

Current rule notes and emphasis on improving the % of patients seen
or contacted within one week of discharge
PCPCH Team definition
Page 2
 Must include non-physician health professionals, such as
 Nurse care coordinator
 Nutritionist
 Social worker
 Behavioral health professional
 Community health workers
 Personal health navigators
 Peer wellness specialist authorized by state plan or waiver

These professionals can operate in variety of ways: such as free
standing, virtual or based at any of the clinic and facilities
Person-Centered Plan
Page 3
 Defined as the plan that shall be developed by the PCPCH and reflect the client and
family/caregiver preferences for:
 education, recovery and self-management
 as well as management of care coordination functions.
 Peer supports, support groups and self care programs shall be utilized to increase the
client and caregivers knowledge about the client’s health and health-care needs.
 The person-centered plan shall be based on the needs and desires of the client including
at least the following elements:
(i) Options for accessing care;
(ii) Information on care planning and care coordination;
(iii) Names of other primary care team members when applicable; and
(iv) Information on ways the team member participates in this care coordination;
 Later on in documentation, required for all clients (Not just ACA)
 Here there is an opportunity to share with Medicaid how this would apply and be
documented for healthy, normally developing clients
Generation of Patient Lists





Lists need to be generated quarterly
The file should be a comma-delimited file
Need to send it via secure file – see FAQ
FFS

Submit a list of FFS clients in format approved by Division

Identify ACA and Non-ACA patients
MCOs

Consult with MCO on their procedures

MCO then submits to OHA

Non-ACA

PCPCH Payment will be integrated into MCOs capitation payments and
covered services at next opportunity (July 2012)

MCOs must use alternative payment methodology. Rule notes that PMPM is
an alternative methodology.
Generation of Patient Lists

Consider opportunities to leverage entities and data sources
they have


Consider others may have data about services that you do not have
in your systems
Consider how to improve diagnostic code labeling in your
processes of care

For example, when using the CAHMI screener consider a part of
the interpretation process labeling visits with related dx codes
Patient agreement to
participate in PCPCH
 Ensure patient engagement, education and agreement to
participate in the PCPCH program are documented within
six months of initial participate
 PCPCH shall assure that for each patient providers working
to develop a person-centered plan within six months
* Important to look at FAQ for definition and documentation
requirements around this.
Patient agreement to participate in
PCPCH:
Documentation Requirements
 See page 7 of FAQ
o Examples of engagement include a phone call during which the patient agrees to be
o
o
o
o
o
o
o
part of the program, or a brief conversation with a patient during an office visit.
The clinic should document in the patient’s medical record the date the patient was
engaged and their agreement to participate.
A passive opt-out provision would not meet the intent of clinics actively engaging
with patients.
A recognized clinic may submit an eligible patient name for PCPCH payment while
attempting to complete and document the patient’s engagement, education, and
agreement to participate.
After 6 month, if the clinic is unable to complete this requirement for a particular
patient, the clinic should not include that patient’s name in the next quarterly patient
list and not request PCPCH payment for that patient.
Efforts to engage a patient, even if unsuccessful, should be documented.
It is not the Oregon Health Authority’s intent to recoup payment for patients that
were unable to be engaged within the initial 6 months.
The Oregon Health Authority is developing educational patient brochures about the
program that can be used for the patient education requirement. These will soon be
available to all recognized clinics.
Documentation Requirements
(Page 5 and 6)
(OPIP Advice: VERY Important to Read)
 Documentation is at the client/person level – not at the
practice level
 Person-centered plan developed with the client or clients
caregiver and in chart
 This is for all clients – not just ACA
 Must provide ONE of the six core services each quarter AND
document the services in the medical recor
Documentation Requirements
(Page 5 and 6)
(OPIP Advice: VERY Important to Read)
 Documentation of Care Coordination
 Panel management is included in the definition
 However, documentation has to be in medical chart.
 Medicaid has not specifically addressed in the rule how panel
management, as a population based analysis, would comply with the
requirement of being documented in the medical record.
 Since they have not specified exactly how this function would end
up documented in a patients record they wish to be as flexible a
possible
 Open to recommendations from participating practices.
Generation of Patient Lists:
Patient Lists Need to Be for People for Whom You
Meet the Documentation Requirements
 Any patients the clinic asks us to assign a retro date on, clinic is
attesting that they have complied with the service and documentation
requirements.
 Time frame for developing a Person Centered Plan within six months:
 For those patients enrolled with a retro date, start the six month clock on
the date the state made the enrollment in the MMIS system.
 Each clinic will receive confirmation of the enrolled patients and DMAP
would not expect a plan to have been developed in the past, we would
expect the other service delivery and documentation requirements to be
made.
 During the first six months if a clinic finds they have PCPCH patients they
have not been able to collaborate on a Person Centered Plan.
Current DMAP Suggestion (One solution – not a requirement):
 Develop a preliminary plan and note in the medical record of attempts to
collaborate with patient, or plan to do so in near future
 Revise that preliminary plan after the patient has been able to be involved
Panel Management
Requirements
(Page 7)
 Required to log on to Provider Portal
 Logging on serves as evidence that the clinic has complied with the
service AND documentation requirements
 Here you have the opportunity to track quality measures AND use as a
panel management tool
 If clinics have their own information technology, can use their own
systems as an alternative. Need to meet specified requirements.
 A clinic can satisfy the required quarterly panel management
documentation by having one team member log on to the provider
portal offered by the Quality Corporation.
Important Documents to Review
 DMAP PCPCH Program Rule:





http://www.dhs.state.or.us/policy/healthplan/guides/aian/141146-147_032212.pdf
Oregon Health Plan, 410-141-0860 (primary rule)
http://www.dhs.state.or.us/policy/healthplan/guides/ohp/main
.html
FAQ:http://health.oregon.gov/OHA/OHPR/HEALTHREFOR
M/PCPCH/docs/pcpch-med-faq.pdf
Supplemental Payment Option Packet, includes the diagnosis code
list for qualified chronic conditions
http://www.oregon.gov/OHA/OHPR/HEALTHREFORM/PC
PCH/docs/dmap-enrollment-packet.pdf?ga=t
So now what?
 At our next learning session, shared care plans will be a
major part of the material delivered
 Technical assistance on other activities (e.g. panel
management, measurement assessment, identification of
SHCN, Bright Futures and related screening)
Clinical example
 JH is a 15 month old Hispanic female. Problems include:
 Prematurity
 Persistent Pulmonary Hypertension
 Patent Ductus Arteriosus
 Developmental Dysplasia of the hip
 GERD
 Due to her complexity, she needs cardiology, orthopedics, Early Intervention,
home health nursing, ophthalmology, etc. In her first year she was on two
chronic medications, oxygen therapy, needed serial bracing for her hips,
required surgical repair of her PDA, and received monthly Synagis injections
this winter.
 Total cost for first year (excluding NICU stay, home health nursing, and EI) was
over $160K. She averages three visits and eight phone calls per month in just
my office. Every Synagis visit the parents need to pull me aside for additional
questions and support
 However, she has no ACA qualifying diagnoses…
Clinical Example
 BR is a 4 year old male with ASD and resulting
developmental delay.
 He is lucky enough to be enrolled in a preschool that gives 30
hours of intensive therapy a week. He is on no additional
medications.
 I receive one letter a quarter from the preschool, and see him
for annual routine well visits and occasional ill visits (he’s had
two in the last year).
 However, he has an ACA-qualifying diagnosis…
The punch line?
 ECHO Staff maintains its commitment to the need for a non-
condition specific approach to identification of CYSHN and
care coordination services.
 ECHO staff maintains the commitment to a focus in this
learning collaborative on the broader concept of medical
home – all of which are reflected and map to the rule
Next Steps
 Learning Session scheduled for May 19
 Location: World Forestry Center
 Carl Cooley, MD visiting as part of TCHIC conference in
June
 Grand Rounds 6/28 from 8-9 am
 Webinar availability
 Training for PCPs on Adolescent SHCN Needs within a Medical
Home
 Sponsored by OCCYSHN
 1:30-3:00