Side-by-Side Summary of State
Medical Home Programs
Last updated March 3, 2011
The “Patient-Centered Medical Home” – a model of practice that emphasizes readily accessible, comprehensive, coordinated care – is
rapidly gaining traction as a way to reform health care. Many states have begun work to implement “medical home” models in their
health programs. This chart describes and compares these state efforts, including the population covered, provider requirements,
payment policies, performance measurement and public reporting, the status of the efforts, and additional relevant notes.
Please note that this chart is not exhaustive, and currently only includes public and public/private initiatives. While there are many
private sector efforts underway, these efforts are not yet part of this document. We will continue to update this chart, but encourage
you to contact us with any additions or comments that could make this chart more useful for the group. Please send additions to Lee
Partridge, Senior Health Policy Advisor, at [email protected].
1875 connecticut avenue, nw ~ suite 650 ~ washington, dc 20009 ~ phone: 202.986.2600 ~ fax: 202.986.2539
email: [email protected] ~ web: www.nationalpartnership.org
1
Side-by-Side Summary of State
Medical Home Programs
Last updated March 3, 2011
State/
program
Population
covered
Provider requirements
Payment policies
Performance
measurement/
Public
reporting
Status
Special
notes
Alabama
All Medicaid
beneficiaries,
except
disabled and
elderly, foster
children,
pregnant
women,
institutionalized persons,
lock-ins, and
enrollees of
private HMOs
Providers must agree to act as
primary care provider for patient. To
earn “enhanced management fees,”
they must complete 3 training
modules on health literacy, medical
home, and Medicaid.
Multi-component case
management fee,
maximum of $2.60
PMPM. Elements of fee
include use of health
information technology
and provision of 24/7
coverage
Certain measures
required.
Primary care
case
management
program, in
place since
2004.
Has very
consumer
oriented
patient
handbook with
clear
statement of
rights,
including
access to
family
planning, and
responsibilities
Patient 1st
program
www.medicaid.al
abama.gov/prog
rams/patient1st/i
ndex_patient1st.
aspx?tab=4
Includes “In-Home Monitoring,” a
complementary program allowing
Patient 1st enrollees with certain
chronic conditions such as diabetes
and hypertension to monitor their
conditions at home by transmitting
readings into a centralized database.
Providers also paid
regular Medicaid fee for
specific medical service
given to patient (fee-forservice)
Providers also share in
savings realized by state
from program.
Alabama
Medworks pilot
Pilot program
open to
Medicaid
beneficiaries
in 3 regions
Each region has non-profit community
network that supports providers in
area. Must include mental health
services.
Patients who utilize ER or
other specialty services
for an issue that could
have been handled as an
outpatient may be
responsible for paying for
the visit
Networks receive $5
PMPM for aged or
disabled beneficiaries;
$30 PMPM for other
Medicaid beneficiaries
1875 connecticut avenue, nw ~ suite 650 ~ washington, dc 20009 ~ phone: 202.986.2600 ~ fax: 202.986.2539
email: [email protected] ~ web: www.nationalpartnership.org
2
State/
program
Colorado
Colorado
Children’s
Healthcare
Access Program
Population
covered
of state
Children
enrolled in
state
Medicaid and
Child Health
Insurance
programs
www.cchap.org
Provider requirements
Payment policies
Performance
measurement/
Public
reporting
Status
Special
notes
Legislative definition : “A practice that
verifiably ensures continuous,
accessible, and comprehensive
access to and coordination of
community based medical care,
mental health care, oral health care,
and related services for a child.”
Responsible for health maintenance
and preventive care, anticipatory
guidance, acute and chronic care,
coordination of meds, specialists, and
therapies, provider participation in
hospital care, and 24 hour telephone
care.
CCHAP-affiliated
practices are reimbursed
for certain preventive
services at a higher fee
than are non-affiliated
practices.
Continuous
quality
improvement
plan that
references
Medical Home
standards and
elements.
Law (SB 07130) enacted in
2007.
Implementation
ongoing by the
Department of
Health Care
Financing and
Policy. State
currently
offering
providers some
assistance with
care
coordination
and case
management.
State
providing
website for
consumers to
see provider
credential and
record of any
complaints.
More detailed standards require:
- same day appointments if
needed
- provider and staff encourage
family participation in health
care decision making
- medical record sharing with
other providers if family
authorizes
- practice has a continuous
quality improvement plan
Colorado
www.healthteam
works.org: click
Multi-payer
PCMH pilot
project that
includes
Practice must meet NCQA level 1
recognition requirements
HealthTeamWorks is the convening
1875 connecticut avenue, nw ~ suite 650 ~ washington, dc 20009 ~ phone: 202.986.2600 ~ fax: 202.986.2539
email: [email protected] ~ web: www.nationalpartnership.org
Using “medical
home index” tool
practices identify
areas for
performance
improvement
initiatives.
By 2010 95%
of all private
practices were
affiliated with
CCHAP.
Measures of
quality of care for
diabetes,
cardiovascular
Operational in
2009 and will
continue
through 2012
3
State/
program
Population
covered
Provider requirements
on Medical
Home
Medicaidenrolled
adults
organization
Connecticut
All individuals
enrolling in
new
statewide
health plan
for uninsured
TBD but providers will be encouraged
to function as patient-centered
medical homes
TBD
disease, tobacco
use and
cessation,
depression, and
prevention; plus
ER and hospital
admission rates,
use of generic
pharmacy, plus
survey of
patient/family and
health team
satisfaction
TBD
All Idaho
All primary care providers and clinics
TBD
TBD
SustiNet plan
www.ct.gov/susti
net
Idaho
Payment policies
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email: [email protected] ~ web: www.nationalpartnership.org
Performance
measurement/
Public
reporting
Status
2009 state law
(HB 6600)
created
SustiNet Health
Partnership
Board to design
and establish
procedures to
implement the
plan. Final
report of Board
filed Jan. 2011
and
recommended
incentives to
providers to
become
medical homes.
Governor’s
Special
notes
Initial focus:
4
State/
program
Illinois
Health Connect
program
www.illinoishealt
hconnect.com
Population
covered
Provider requirements
residents
are eligible to participate
All Medicaid
beneficiaries,
except those
in HMO or
dual eligibles;
foster
children,
children who
receive
Supplemental
Security
Income (SSI),
institutionalized persons,
refugees,
American
All primary care providers and clinics
are eligible to participate. Provider
signs addendum to standard Medicaid
physician participation agreement and
promises to:
- serve as patient’s primary care
provider
-have hospital privileges or
arrangements for admission
-makes referrals to specialists
-24/7 coverage
-maintain office hours of at least 24
hrs/week (solo practices) or 32
hours/wk (group practices)
-follow recognized preventive care
guidelines
Payment policies
$2 PMPM per child, $3
for parent, $4 for elderly
or disabled
Plus regular FFS fees
Bonus (at least $20 per
qualifying patient for 2010
performance) for meeting
or exceeding designated
HEDIS percentile scores
in:
-immunization of 2 yr olds
-dev. screen
-asthma mgt.
-HbA1C testing
-mammograms
1875 connecticut avenue, nw ~ suite 650 ~ washington, dc 20009 ~ phone: 202.986.2600 ~ fax: 202.986.2539
email: [email protected] ~ web: www.nationalpartnership.org
Performance
measurement/
Public
reporting
Provider profiling,
not publicly
reported, using
20 HEDIS and
HEDIS-like
measures, viz:
Child imm, lead
testing,
asthma/diabetes
care, well child
and adolescent
well care,
prenatal
frequency/timelin
ess, depression,
cervical cancer
Status
Special
notes
Select
Committee on
Health Care
recommended
(10/08) state
support PCMH
model.
building IT
capacity and
assuring
adequacy of
primary care
provider
workforce
State Primary
Care Assn. has
grant (5/09) to
facilitate safetynet clinics
transformation
into medical
homes.
Primary care
case
management
program,
began in 2007.
State provides
special secure
web portal to
support PCP
and grant
access to
patient roster.
Beginning
5/2008 will
also give
patient’s
Medicaid claim
history and 7
years of
immunization
data
5
State/
program
Population
covered
Provider requirements
Indians,
Alaska
natives, or
other
population
already
managed
under
another
program
-manage chronic disease
Payment policies
Performance
measurement/
Public
reporting
Status
screen, adult
access to
preventive care,
rate of ER visits
and ambulatory
care sensitive
hospital visits
Enrollees will be assigned a PCP if
they do not choose one.
Complimentary disease management
program (“Your Healthcare Plus”)
available for chronically ill
beneficiaries, currently targeting
children with asthma and disabled
adults
Beneficiaries
under 21 may
obtain
preventive
health care
from approved
local health
department,
school-based
clinics, and
women’s
health care
providers
without referral
from PCP.
Calculates
statewide
benchmarks
Healthy kids exams without costsharing provided without cost-sharing
from birth through age 20
Iowa
www.idph.state.i
a.us/hcr_commit
tees/medical_ho
me.asp
All state
residents;
initial focus
on Medicaid
eligible
children
Leads team of individuals at the
practice level who collectively take
responsibility for ongoing health care
of patients. Provides or arranges for
care by other professionals; care
coordinated with community.
Participates in NCQA voluntary
recognition process or similar system
to demonstrate practice has capacity
to provide patient-centered services
consistent with medical home model.
Reimbursement to be
studied by state depts.
and recommendations
made to insurers and
state program
administrators.. Assumes
care management fee
add on to FFS. Allows
gain sharing, quality
incentives.
Recognizes value of IT.
Primary care provider can be:
- MD who is family practitioner, GP,
1875 connecticut avenue, nw ~ suite 650 ~ washington, dc 20009 ~ phone: 202.986.2600 ~ fax: 202.986.2539
email: [email protected] ~ web: www.nationalpartnership.org
Special
notes
Voluntary
engagement in
performance
measurement
and
improvement.
Section of an
omnibus health
reform bill (HF
2539) which
became law
May 2008
Measures to be
specified by dept.
For children,
suggest
immunization, ER
use, well child
and oral health
Iowa Dept. of
Health Medical
Home System
Advisory
Council, a
broad
stakeholder
Legislation
envisions
statewide
medical home
system that
offers care
coordination,
data collection
and analysis,
other
assistance
and monitors
quality
6
State/
program
Population
covered
Provider requirements
-
Payment policies
pediatrician, internist, OB-gyn
Advanced nurse practitioner
Physician assistant
Chiropractor
Performance
measurement/
Public
reporting
Status
Special
notes
utilization rates.
group, is
helping
implement.
In October
2010
Medical home
system would
support both
public and
private
programs,
although
implementatio
n would begin
w/ children
enrolled in
Medicaid
program.
The certification workgroup of the
Medical Home Advisory Council is
developing recommendations for
more detailed certification criteria
Multi-payer
medical home
collaborative
formed in fall
2011.
Kansas
Medicaid,
CHIP, and
state
employee
benefit
program
Physician or other personal care
provider in a physician-directed team
To be developed by
Kansas Health Policy
Authority and Kansas
State Employees Health
Care Commission
To be developed
Louisiana
Medicaid
beneficiaries
Legislative definition: “A medical
home system of care …guided by a
personal primary care provider who
coordinates and facilitates preventive
and primary care…” The system will
be integrated and incorporate primary
care providers, specialty care groups,
and hospitals. All participating
Multiple components:
$1.50 PMPM base
management fee, plus
P4P opportunities of –
Up to $0.75 lower ER
use;
$0.75 for extended office
hours for appointments;
TBD by Louisiana
Dept. of Health
and Hospitals
CommunityCAR
E 2.0 program
1875 connecticut avenue, nw ~ suite 650 ~ washington, dc 20009 ~ phone: 202.986.2600 ~ fax: 202.986.2539
email: [email protected] ~ web: www.nationalpartnership.org
Requirement
and definition
included in law
adopted in
2008 (House
substitute for
Senate Bill 81).
Stakeholder
workgroups
established and
meeting.
Health Care
Reform Act of
2007 directed
state to
develop and
implement the
system.
7
State/
program
Population
covered
Provider requirements
Payment policies
providers must have interoperable
electronic medical records.
$0.50 for attaining NCQA
or JCAHO recognition
$0.25 for EPSDT screen
at primary site
$1.00 if 90% are up to
date in immunizations
Must participate in state electronic
immunization database; make direct
medical care in office available at
least 32 hours week; large practices
must have extended hours of at least
6 hours week.
Maine
PCMH Pilot
www.mainequalit
ycounts.org
Maryland
http://dhmh.mary
land.gov/pcmh
Medicaid,
Medicare and
private health
plan
enrollees
who enroll in
multi-payer
pilot project
Maine has
also been
selected to
participate in
Medicare
medical
home demo
Patient
participation
in the PCMH
program is
voluntary, but
Dept. of
Primary care practice located in
Maine with at least one full-time
primary care physician or nurse
practitioner. Must have or achieve
w/in 6 months Level l score on NCQA
PCC-PCMH recognition tool and
commit to using a team-based care
model.
Primary care practices, both adult and
pediatric
All practices participating in Pilot
project must obtain NCQA level 1
recognition within 6 months and level
New state law waives law
that prohibits
collaboration of carriers
or providers on payment
when participating in the
PCMH program
1875 connecticut avenue, nw ~ suite 650 ~ washington, dc 20009 ~ phone: 202.986.2600 ~ fax: 202.986.2539
email: [email protected] ~ web: www.nationalpartnership.org
Performance
measurement/
Public
reporting
Status
Special
notes
CommunityCA
RE 2.0
implemented
January 1,
2011
Designed to
measure
progress of
practice in 10
core
competencies.
26 pilot
practice sites
announced
7/09; 22 adult
and 4 pediatric;
began
operations later
that year.
Maine PCMH
Working
Group has 2
consumer
members;
Pilot practices
asked to
involve
patients and
families in
practice
redesign
Pilot practices
must report on
performance
using measures
for at least one of
following:
HB 929
approved by
the Governor
4/13/ 2010
established a
state PCMH
Workgroup
draws from
multiple
stakeholder
groups in state
8
State/
program
Massachusetts
Massachusetts
Patient Centered
Medical Home
Population
covered
Provider requirements
Health may
require
certain
Medicaid
beneficiaries
to enroll
2 within 18 months
Multi-payer
pilot project,
including
Medicaid
State will recognize nurse practitioner
led practices that meet NCQA PCMH
standards
Achieve NCQA PCMH tier 1
requirements plus use of non-MD
staff in care management, promote
patient self-management, maintain
and use patient registry.
Payment policies
Pilot practices to be paid
combination of fixed
(PMPM) amount and
incentive bonus based on
quality. Fixed payment
adjusted by payer status,
NCQA recognition, and
practice size. (Small
practices paid more.)
Includes start-up
infrastructure payments
payments (max. $15,000
per site in year 1, $3,500
in year 2), ongoing
1875 connecticut avenue, nw ~ suite 650 ~ washington, dc 20009 ~ phone: 202.986.2600 ~ fax: 202.986.2539
email: [email protected] ~ web: www.nationalpartnership.org
Performance
measurement/
Public
reporting
Status
Special
notes
-diabetes
-heart/stroke
management
-asthma control
program with a
single definition
of a PCMH,
common set of
quality
measures, and
uniform
payment
methodology,
all to be
determined by
the Maryland
Health Care
Commission.
Also requires
all insurers
doing at least
$90M in health
benefit
premium in
state, and all
Medicaid
HMOs, to
participate
Program will
sunset
December 31,
2015.
Pediatric
measures TBD
50 practice pilot
to begin 1/2011
Requirement
included in
omnibus health
care quality
improvement
New law also
creates state
quality and
cost council
which would
9
State/
program
Population
covered
Provider requirements
Initiative
Practices must participate in
MassHealth program or have contract
with MassHealth HMO.
www.mass.gov/h
hs/medicalhome
State initiative will provide technical
support and learning collaboratives to
assist practice transformation and
preparation for NCQA recognition
Payment policies
Performance
measurement/
Public
reporting
Status
Special
notes
supplemental payment
($1.50 PMPM), separate
payment for care
management ($0.60
PMPM for child; $1.50
PMPM adults; $6 PMPM
for seniors), and bonus
payments based on
shared savings and
quality performance
law (Senate
2863) enacted
August 2008.
determine
what
performance
measures and
cost
information all
providers
would be
required to
submit to the
state. Data
would be
reported on
consumer web
site.
Three part payment to
practices:
$3 PMPM for care mgt
$1.50 PMPM for practice
transformation support
Up to $3 PMPM for
performance
improvement
Medicare will pay
practices about $2 more
PMPM
Payers will also pay
central administrator of
project 26 cents PMPM
for services, including
learning collaboratives,
evaluation
Project steering
committee in
place Dec.
2010; project to
begin later in
2011
46 practices
selected for
participation in
12/10.
.
Michigan
Michigan
Primary Care
Transformation
Project (MiPCT)
http://www.mipcc
.org
Commercial,
Medicaid and
Medicare
patients
served by
participating
practices
Practices designated as BCBS
Michigan PCMH as of June 2010.or
have achieved NCQA recognition at
level 2 or 3 level
Project lead by coalition of payers and
providers; co-chairs are Dept. of
Community Health and U. of Michigan
Health System
1875 connecticut avenue, nw ~ suite 650 ~ washington, dc 20009 ~ phone: 202.986.2600 ~ fax: 202.986.2539
email: [email protected] ~ web: www.nationalpartnership.org
10
State/
program
Population
covered
Provider requirements
Payment policies
Performance
measurement/
Public
reporting
Status
Special
notes
Minnesota
Enrollees in
Medicaid,
SCHIP and
state funded
program for
uninsured;
state
employee
group
insurance;
private plans
regulated by
state,
Medicare
beneficiaries
All health care homes must:
- Offer patient ongoing long term
relationship with clinician,
including advanced practice
nurses and PAs
- Provide care coordination
- Enhance patient/family
participation in decision making
- Ensure use of HIT
- Must participate in health care
home collaborative re QI
- Meet annual benchmarks set by
state for patient health, patient
experience, and cost
effectiveness
Per person pmts for care
coordination, adjusted for
patient care complexity.
15% payment increase
for patients: (1) whose
primary language is not
English, and/or (2) have
serious and persistent
mental illness
Diabetes,
depression,
cardiovascular,
use of HIT
survey.
State law, May
2008. Medical
home
standards and
new payment
system
developed by
state DHS and
Health Dept.
Multiple
working groups
assisting.
Care
coordination
fees would be
funded from
savings in
other
segments of
medical
programs,
including HMO
capitation fees
if necessary
Minnesota
has also
been
selected as
one of the
states
participating
in Medicare
medical
home demo
Entire state
TBD
TBD
Health home
program
www.health.stat
e.mn.us/healthre
form/homes/inde
x.html
Mississippi
Providers might also
qualify for separate, add’l
quality incentive
payments
1875 connecticut avenue, nw ~ suite 650 ~ washington, dc 20009 ~ phone: 202.986.2600 ~ fax: 202.986.2539
email: [email protected] ~ web: www.nationalpartnership.org
CAHPS practice
level patient
experience
survey to be
required
beginning
9/2012.
Rule that
established
standards for
certification
adopted Nov.
2009. State
health
measures rule
adopted 12/09.
TBD
House bill 1192
signed into law
March 17,
2010, directs
Board of Health
to adopt
11
State/
program
Population
covered
Provider requirements
Payment policies
Performance
measurement/
Public
reporting
Status
Special
notes
guidelines for
MDs, NPs, and
PA practices
that incorporate
PCMH
principles. Law
effective 7/1/10
Nebraska
Medicaid Pilot
Medicaid
beneficiaries
who enroll in
pilot program
www.hhs.state.n
e.us/med/Pilot/
A provider of primary health care
services with capacity to provide
comprehensive, coordinated health
care for patients, including use of IT,
with focus on ongoing prevention and
patient/family participation in health
care decision making and care plan
development
$2 PMPM initially, $4
PMPM if qualifies for tier
2 under state standards,
plus 50% bonus on office
visits
State-developed standards have two
levels
New Hampshire
MultiStakeholder
Pilot Program
Private pay
and Medicaid
patients in
participating
practices
Participating practices must meet
NCQA PCC-PCMH tier l practice
recognition requirements
Authorized by
Nebraska law
(LB 396, signed
by Gov.
4/22/09;
effective 9/09.
Pilot programs
to begin not
later than
1/1/2012;
terminates
6/30/2014.
Two rural sites
operational
early 2011.
Eleven practice
sites selected
1/09.
Implementation
ongoing.
Law creates
Advisory
Council to
advise state re
implementing;
7 members, of
which 6 are
primary care
MDs and one
a hospital
representative.
Coordination
and support
provided by
NH Citizens
Health
Initiative
www.steppingup
nh.org
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email: [email protected] ~ web: www.nationalpartnership.org
12
State/
program
Population
covered
Provider requirements
Payment policies
Performance
measurement/
Public
reporting
Status
New Jersey
Medicaid and
Work First NJ
beneficiaries
Primary care providers using multidisciplinary team and having certain
health information technology
capacities
TBD
Cost savings;
outcomes and
hospitalization
rates for persons
with chronic
illness or frail
elderly; health
screening rates
Diabetes plus two
additional chronic
conditions for
adults; well child
care/prevention
plus two of
ADHD, obesity,
or asthma
Law signed
9/20/10;
implementation
can begin by
1/2011
Pilot program
New York
Adirondack
Medical Home
Multipayer Pilot
Program
www.adkmedical
home.org
Medicaid,
CHIP, state
employees,
and private
pay patients
of the
participating
practices;
beginning in
2011,
Medicare
beneficiaries
PMPM plus bonus for
quality performance.
State is providing grant
support for health
information technology
support as well; $7 M
state health IT grant
announced 9/09
.
New York
Statewide
Health Care
Home Program
Medicaid and
CHIP
enrollees
Must meet NCQA tier 1,2, or 3
recognition.
After Dec. 2012, level l practices will
not be eligible for enhanced
payments.
FFS E&M and Preventive
Medicine claims will
receive add-on incentive
payment ranging from
$5.50 to $21.25
depending upon NCQA
recognition tier.
NCQA PCMH recognized
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email: [email protected] ~ web: www.nationalpartnership.org
Certified homes
will be required to
submit data to
state as
requested
State
Legislature
authorized
Medicaid, CHIP
and state
employee
participation
[section 26 of
omnibus
budget bill]
4/09. Practices
selected and
project
underway
2010.
State
Legislature
authorized 4/09
[section 25 of
omnibus
budget bill]
Special
notes
FQHC
[Hudson
Headwaters]
in Adirondack
is playing
convening role
Nurse
practitioners
can qualify to
receive
incentive
payments
Provider
certification
13
State/
program
Population
covered
Provider requirements
Payment policies
Performance
measurement/
Public
reporting
practices in Medicaid
HMO networks can be
paid PMPM of $2 to $6
per month depending
upon recognition tier.
North Carolina
Community Care
of North Carolina
www.community
carenc.com
All Medicaid
beneficiaries
including dual
eligibles
Beginning
late 2011
Medicare
beneficiaries
in 7 counties
(not counties
participating
in the section
646 demo) as
part of multipayer
demonstratio
n project.
Practice that agrees to participate in
state’s primary care patient
coordination system (Carolina
Access) and provide, direct, and
coordinate the health care and
utilization of health care services of
practice enrollees. All necessary
medical services must be provided
directly or authorized and arranged
through the practice.
Practice is supported by regional
CCNC entity which assists in care
management, identifies resources,
collects performance data, and
provides feedback to practice.
Total of $60M in state IT
grants announced 9/09;
most will help support
PCMH initiatives across
state
PMPM fee paid in
addition to regular FFS
payments. Currently $3
PMPM; $5 for aged, blind
and disabled patients
CNCN networks also
receive PMPM fee for
each beneficiary.
1875 connecticut avenue, nw ~ suite 650 ~ washington, dc 20009 ~ phone: 202.986.2600 ~ fax: 202.986.2539
email: [email protected] ~ web: www.nationalpartnership.org
Status
Special
notes
requirements
adopted 12/09.
Payment
incentives
began 7/1/10.
Practices receive
monthly and
quarterly data on
utilization to allow
comparison w/
peer group.
In place
since.1998;
statewide
beginning 2002
State granted
federal
demonstration
waiver (section
646) to expand
program to
include dual
eligibles
Will open
program to
Medicare
beneficiaries
who are not
dual eligibles
in 2012
14
State/
program
Population
covered
Provider requirements
Payment policies
Performance
measurement/
Public
reporting
Status
Special
notes
Ohio
All residents
of Ohio
Council adopted 4/10 a medical home
description patterned on the PCMH
Joint Principles endorsed by AFP,
AAP, ACP, and AOA.
TBD
TBD
Council
adopted
numerous
proposals of
its Consumer
Engagement
Task Force,
including
encouraging
existing PCMH
practices to
partner w/
existing
Community
Chronic
Disease SelfManagement
programs
Selected
Medicaid
enrollees w/
chronic
conditions
Direct care management support
(RNs) for identified Medicaid
beneficiaries with high risk chronic
conditions, plus assistance to
providers in practice redesign to
improve quality and efficiency.
No additional payment to
providers Nurses hired
by state.
Governor’s
created Ohio
Health Care
Coverage and
Quality Council
by Exec. Order
5/09; Council
created task
force on
medical home;
began meeting
9/09;recommen
dations
adopted by
Council 4/10;
special steering
committee
formed to
encourage
adoption of
model by all
payers
Began in
January 2008
Medicaid
beneficiaries
except those
Physician, physician assistant,
advanced nurse practitioner; FQHC,
Rural Health Clinic, Indian Health
Regular fee for service
payments plus monthly
case management fee,
Bonus payment
to practices that
meet certain
Began in
January 2009
State has
applied for
federal
www.healthcarer
eform.ohio.gov/h
ccqc.aspx
Oklahoma
Health
Management
program
Oklahoma
1875 connecticut avenue, nw ~ suite 650 ~ washington, dc 20009 ~ phone: 202.986.2600 ~ fax: 202.986.2539
email: [email protected] ~ web: www.nationalpartnership.org
15
State/
program
Population
covered
Provider requirements
Payment policies
Performance
measurement/
Public
reporting
Sooner Choice
program
also enrolled
in Medicare
or state’s
home and
community
based care
program
waiver
Services clinic.
peer grouped by type of
panel (child/adult and
child/adults only) and
capabilities of practice.
Ranges from $3.03 (tier
1, child caseload) to
$8.69 (adults, tier 3)
PMPM. Tier 1 practices
can receive additional
add-on payments for 24/7
voice to voice (50 cents)
and electronic link to
state agency (5 cents).
targets for child
health exams,
cancer screens,
reduced ER use,
appropriate Rx
use, and
immunization
goals.
www.okhca.org/
medical-home
Providers can be certified as meeting
one of three tiers. All must
provide/coordinate primary and
preventive services, track tests and
referrals, maintain Rx list, and provide
patient education and support.
Higher tiers must provide more after
hours care, offer 24/7 voice to voice
coverage, develop proactive care
teams, and document patient selfmanagement plan for chronic disease
patients.
Status
Special
notes
approval of
Medicaid
funding for 4
regional
community
networks to
support
practice sites
with access to
IT, care
coordination,
and
community
resources
FQHC, RHCs, and IHS
do not qualify for case
management fee.
Oregon
Patient centered
primary care
home program
Beneficiaries
of public
programs,
including
state
employees,
but available
to others
Proposed standards and measures
for Patient Centered Primary Care
Homes presented to Health Authority
4/10. Full report available at:
www.oregon.gov/OHPPR/HEALTHRE
FORM/PCPCH/PCPCHStandardsAdv
isoryCommittee.shtml
TBD.
1875 connecticut avenue, nw ~ suite 650 ~ washington, dc 20009 ~ phone: 202.986.2600 ~ fax: 202.986.2539
email: [email protected] ~ web: www.nationalpartnership.org
TBD
House bill
2009, signed
into law 6/09,
established
new Oregon
Health
Authority, to
operate
existing public
health
insurance
programs and
plan for, then
implement,
HB 2009
directs OHA to
be attentive to
cultural and
linguistic
competency,
including
requirement
that it
collaborate w/
private
insurers to
develop and
test use of
16
State/
program
Pennsylvania
Chronic Care
Initiative
http://rxforpa.co
m/ChronicCare.h
tml
Rhode Island
Connect Care
Choice PCCM
Population
covered
All
beneficiaries
(Medicaid,
and
commercial)
enrolled in
practices
participating
in regional
medical
home pilots.
Beginning in
2011,
Medicare
beneficiaries
in certain
counties
Adults
enrolled in
Medicaid or
Medicare
programs but
not covered
by other
Provider requirements
Patient-centered medical home
practice redesign initiative focusing on
patients with chronic conditions.
Initial focus: diabetics and pediatric
asthma. Model based on the four
professional society Joint Principles.
Medicaid HMOs in region required to
participate in pilot
Primary care practices who agree to
help coordinate care
Participating Practices
adopt e-prescribing, ebilling and
computerized
Payment policies
Practices receive
increased reimbursement
for attaining PCC-PCMH
recognition, and also
P4P. Funding supplied
by participating insurers,
including state Medicaid
program. Payment
policies not uniform
across the several
regions.
Multi-component PMPM
based on enhanced
services offered
Special additional PMPM
for case managers for
identified high risk
1875 connecticut avenue, nw ~ suite 650 ~ washington, dc 20009 ~ phone: 202.986.2600 ~ fax: 202.986.2539
email: [email protected] ~ web: www.nationalpartnership.org
Performance
measurement/
Public
reporting
Required.
Status
Special
notes
comprehensive
state health
reform,
including
support for
primary care
home program.
First pilot
located in SE
Pennsylvania
region in May
2008; now
operational in
other regions
community
health workers
to assist in
certain
communities.
Initiative lead
by Governor’s
Office of
Health Care
Reform
.
In operation
since 2007
Effective
7/1/09, all
adult Medicaid
non-dual
beneficiaries
must enroll
either in
17
State/
program
Population
covered
Provider requirements
Payment policies
third-party
insurance,
nor enrolled
in a Medicaid
HMO
evidenced-based
clinical decision
guidelines at the point
of care.
patients
Physicians partner with Nurse Care
Managers (integrated into or
dedicated to practice) to coordinate
chronic care to encourage patient
self-management and prevent
avoidable complications
Rhode Island
Chronic Care
Sustainability
Initiative project
Texas
All insured
adults
including
Medicare
beneficiaries
with chronic
illnesses
Pilot sites agree to seek NCQA
recognition, participate in training in
Chronic Care model, and hire nurse
care manager
Children
enrolled in
Medical practice, or coalition of
practices, that have
Rhode Island Insurance
Commissioner is convenor.
Performance
measurement/
Public
reporting
Status
Connect Care
Choice
(primary care
case
management
program) or
Rhody Health
Partners
(health plan
model), the
Medicaid HMO
plans.
Both payments in addition
to regular FFS
reimbursement
Medicaid HMOs required
to participate in payment
to practices enrolled in
pilot
$3 PMPM for
implementing medical
home features, plus $.80
PMPM for onsite care
management
Initial focus:
coronary artery
disease,
diabetes,
depression,
advising
smokers to quit
measures; cost
and utilization
measures for
ER, Rx, and
hospital
admissions
Negotiated amount based TransforMED
upon budget submitted by assessment tool
1875 connecticut avenue, nw ~ suite 650 ~ washington, dc 20009 ~ phone: 202.986.2600 ~ fax: 202.986.2539
email: [email protected] ~ web: www.nationalpartnership.org
Special
notes
Initial 5 pilot
sites began
Oct. 2008;
expansion to 8
more April
2010
18
State/
program
Population
covered
Provider requirements
Payment policies
Health home
pilot
Medicaid
program
been participating in Medicaid
program since June 2008. State will
select 8 pilot sites based on
competitive application process.
practice and agreed to by
state Medicaid agency
NCQA PCC-PCMH recognition
required Practices must also meet
minimum standards for adoption,
implementation, and deployment of
health information technology.
PMPM varies based on
NCQA score; up to $2.39
month.
Vermont
Blueprint for
Health
http://hcr.vermon
t.gov/blueprint_f
or_health
Washington
Multipayer
Medical Homes
Pilot
www.medicalho
me.org
Commercial,
Medicare and
Medicaid
patients
enrolled in
participating
practices
Patients
enrolled in
participating
health plans,
including
Medicaid
HMOs
Providers supported by communitybased care coordination teams
(CCTs) to assist with care
coordination and patient education,
including workshops to enhance
patient self-management abilities.
Flexible, but preference for practices
that have participated in chronic care
collaborative, or are participating in
current state medical home
collaborative, or have achieved at
least NCQA PCMH tier 1 recognition
level.
Performance
measurement/
Public
reporting
at 6, 12, 18 and
24 months.
Status
Special
notes
Project began
in 2008; by end
of 2010 12
sites
participating in
pilot. Law
passed in 2010
(Act 128)
required
expansion of
project
statewide.
Implementing
regulations
effective
3/5/11.
SSB 5891, now
law,
encourages
adoption of
medical home
model;
provides
exemption from
Vermont has
also launched
Healthier
Living
Workshops
across state to
help residents
with chronic
illness learn
techniques for
managing their
condition and
working with
providers in
partnership.
CAHPS group
and clinician
survey.
Practices also receive
funding for expanded HIT
Payers share in cost of
administrative entity in
each hospital service
area for cost of
Community Health
Teams.
Two options
recommended; both
assume practice at risk to
achieve some agreedupon level of reduction in
ER and hospital use and
savings will be shared
1875 connecticut avenue, nw ~ suite 650 ~ washington, dc 20009 ~ phone: 202.986.2600 ~ fax: 202.986.2539
email: [email protected] ~ web: www.nationalpartnership.org
Reduction in
preventable ER
visits and hospital
admissions over
3 years from
baseline, plus
HEDIS scores for
cancer screens
19
State/
program
West Virginia
Population
covered
Provider requirements
Payment policies
Medicaid
beneficiaries
1875 connecticut avenue, nw ~ suite 650 ~ washington, dc 20009 ~ phone: 202.986.2600 ~ fax: 202.986.2539
email: [email protected] ~ web: www.nationalpartnership.org
Performance
measurement/
Public
reporting
Status
and managing 3
chronic
conditions
(diabetes, heart,
depression) and
patient
experience
surveys
state antitrust
laws for payers
in pilots.
Special
notes
This pilot
focuses on
incentives to
reduce ER and
hospital use by
strengthening
primary care
and care
coordination.
Goal is to
implement by
Jan. 2011.
Provider
training funded
under federal
Medicaid
transformation
grant beginning
in 2008; West
Virginia Health
Improvement
Institute
operates
20