PCMH INITIATIVE MEDICAID PAYMENT MODEL: CARE MANAGEMENT AND COORDINATION Sample Clauses

PCMH INITIATIVE MEDICAID PAYMENT MODEL: CARE MANAGEMENT AND COORDINATION. 1. PCMH Initiative Participants will receive care management and coordination payment to support embedded care coordination services as a PMPM rate according to their performance during the 4Q17-2Q18 performance period: a. Participants that met the required 2.5% benchmark for the defined performance period will receive PMPM rates of: i. Adult Beneficiaries (19 years and above) 1. $3.00 for Adult General Low Income Beneficiaries (TANF) 2. $5.00 for Healthy Michigan Plan Beneficiaries (HMP)

PCMH INITIATIVE MEDICAID PAYMENT MODEL: CARE MANAGEMENT AND COORDINATION. 1. PCMHs will receive care management and coordination payment to support embedded care coordination services as a PMPM rate of: a. Adult Beneficiaries (19 years and above) i. $3.00 for Adult General Low Income Beneficiaries (TANF) ii. $5.00 for Healthy Michigan Plan Beneficiaries (HMP) iii. $7.00 for Aged, Blind and Disabled Beneficiaries (ABD) b. Pediatric Beneficiaries (18 years and under) i. $2.75 for Pediatric General Low Income Beneficiaries (TANF) ii. $7.00 for Aged, Blind and Disabled Beneficiaries (ABD) 2. To receive the PMPM care management and coordination payment, Practices must: a. Maintain care management and coordination expectations as defined in Appendix C. b. Maintain care management and coordination performance above the Initiative defined benchmarks (see Appendix C) on the following two metrics: i. The percentage of a Practice’s attributed patients receiving care management and coordination services; and ii. The percentage of a Practice’s attributed patients receiving a timely (within 14 days) follow- up visit with a Provider following a hospital inpatient stay. c. MDHHS reserves the right to update the benchmarks outlined Appendix C based on overall participant performance, regular metric specification maintenance or other applicable events. In the event that the benchmarks must be updated, MDHHS will provide sixty (60) days written notice to participants. A Medicaid beneficiary must be both eligible (see Appendix D) to be attributed and have a selected/assigned primary care provider (PCP) that is participating in the PCMH Initiative to be considered part of the PCMH Initiative population. Care Coordination and/or Practice Transformation payment(s) made as part of the PCMH Initiative payment model will be made based on this attribution process. 1. The State of Michigan has identified exclusion criteria to determine beneficiaries eligible to be attributed in the PCMH Initiative. In general, beneficiaries must be enrolled in a Medicaid Health Plan, receive the full scope of Medicaid services and not be attributed to another Medicaid program/initiative which possess a potentially duplicative service set or payment model. (See Appendix D for more details). 2. The beneficiary’s attributed provider is determined based on the selected/assigned primary care provider (PCP) reported to the State of Michigan by each Medicaid Health Plan. 3. Beneficiaries are considered part of the PCMH Initiative population if the selected/assigned PCP is employe...