Description of Delivery System and Provider Payment Initiatives. (i) Description of delivery system and provider payment initiatives included in the capitation rates
Description of Delivery System and Provider Payment Initiatives. (i) Description of delivery system and provider payment initiatives included in the capitation rates CICIP. Effective July 1, 2018, CICIP was developed to increase alignment of quality improvement strategies and goals between ODM, MCPs, and both public and nonprofit hospital agencies. CICIP is a quality payment program in which hospital agencies are paid based on the value of their quality improvement efforts. In recognition of implementing and executing quality improvement initiatives, monthly CICIP PMPM payments are made to eligible hospital agencies from the MCPs. These payments are allocated to hospital agencies based on historical utilization data. In addition, participating hospital agencies will be eligible to receive annual quality improvement payments if they adhere to data reporting requirements and achieve performance improvements based on criteria established by ODM. The sum of CICIP PMPM amounts and annual quality improvement payments will not exceed average commercial reimbursement for physician services. The goals of CICIP align with the ODM goals: improve healthcare for Medicaid beneficiaries at risk for or currently with an opioid or other substance abuse disorder, along with improving care coordination. Each participating hospital will receive supplemental payments under the Medicaid program for physician and other professional services that are covered by the Medicaid program and provided to Medicaid recipients. Supplemental Dispensing Fee. Effective January 1, 2020, ODM implemented a supplemental dispensing fee for retail pharmacies. Members receiving Medicaid services, including those enrolled in managed care, may be at risk of not receiving their prescribed drugs due to the high cost for pharmacies to fill prescriptions coupled with low dispensing fees. This is especially prevalent in underserved areas of the state. This payment arrangement is intended to ensure that pharmacies received adequate reimbursement for Medicaid members so that members continue to receive access to the pharmacy services they require. To determine the amount of the dispensing fee each individual pharmacy is to receive, pharmacies are stratified into three tiers based on total dispensed scripts across all markets. ODM will provide the MCPs with a listing of each pharmacy’s tier assignment and corresponding dispensing fee. Retail pharmacies excluded from this requirement include: 340B covered entities, internet-based pharmacies, mail order pharmacies, and nursi...
Description of Delivery System and Provider Payment Initiatives. (i) Description of delivery system and provider payment Initiatives included in the capitation rates Effective July 1, 2018, the Care Innovation and Community Improvement Program (CICIP) was developed to increase alignment of quality improvement strategies and goals between ODM, MCPs, and both public and nonprofit hospital agencies. CICIP is a quality payment program in which hospital agencies are paid based on the value of their quality improvement efforts. In recognition of implementing and executing quality improvement initiatives, monthly CICIP per member per month (PMPM) payments are made to eligible hospital agencies from the MCPs. These payments are allocated to hospital agencies based on historical utilization data. In addition, participating hospital agencies will be eligible to receive annual quality improvement payments if they adhere to data reporting requirements and achieve performance improvements based on criteria established by ODM. The sum of CICIP PMPM amounts and annual quality improvement payments will not exceed average commercial reimbursement for physician services. The goals of CICIP align with the ODM goals: improve healthcare for Medicaid beneficiaries at risk for or currently with an opioid or other substance abuse disorder, along with improving care coordination. Each participating hospital will receive supplemental payments under the Medicaid program for physician and other professional services that are covered by the Medicaid program and provided to Medicaid recipients.
Description of Delivery System and Provider Payment Initiatives. (i) Description of delivery system and provider payment initiatives included in the capitation rates Members receiving Medicaid services, including those enrolled in managed care, may be at risk of not receiving their prescribed drugs due to the high cost for pharmacies to fill prescriptions coupled with low dispensing fees. This is especially prevalent in underserved areas of the state. This payment arrangement is intended to ensure that pharmacies received adequate reimbursement for Medicaid members so that members continue to receive access to the pharmacy services they require. To determine the amount of the dispensing fee each individual pharmacy is to receive, pharmacies are stratified into three tiers based on total dispensed scripts across all markets. ODM provides the MCPs with a listing of each pharmacy’s tier assignment and corresponding dispensing fee. Retail pharmacies excluded from this requirement include: 340B covered entities, internet-based pharmacies, mail order pharmacies, and nursing facilities.
Description of Delivery System and Provider Payment Initiatives. (i) Description of delivery system and provider payment initiatives included in the capitation rates Hospital Additional Payment. Effective for the January 1, 2021 through December 31, 2021 period, this new payment arrangement features an enhancement to the inpatient and outpatient hospital fee schedule due to the significant and continuing challenges resulting from the COVID-19 public health emergency. This new payment arrangement is intended to increase hospital reimbursement above historic levels. Under the new preprint, in-state hospitals will receive a quarterly payment initially calculated based on utilization from a prior period and ultimately reconciled based on utilization from the incurred period. Enhanced payment amounts will be determined separately for inpatient and outpatient services as outlined in the preprint. To determine payment amounts by hospital, ODM will apply a per discharge amount for inpatient services and a percentage of base payments for outpatient services. ODM estimates these payments will increase CY 2021 aggregate Medicaid expenditures for inpatient and outpatient hospital services by approximately $1.4 billion. The payment increases will apply to all inpatient and outpatient services provided to MMC enrollees. To evaluate whether provider payment levels with consideration of the HAP adhered to upper payment limit requirements by CMS, we relied on analysis provided by ODM. As part of the demonstration, Medicare- equivalent payment levels were estimated using a cost-based methodology where inpatient and outpatient Medicare cost-to-charge (CCR) ratios were calculated using Medicare cost reports and applied to Medicaid charge data. Base Medicaid payments from each hospital's Medicaid cost report were used to calculate base Medicaid payment levels. All methodologies and adjustment factors applied in this context are consistent with the fee-for-service upper payment limit methodologies. Modeled effects of the state directed payments and the current pass-through payments were used to calculate the respective effects of these payments in comparison to the Medicare- equivalent level of reimbursement.
