TOPIC QUESTION ANSWER CommunityCARE 2.0 Transition Did CommunityCARE end as of January 1, 2011?

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1 TOPIC QUESTION ANSWER Transition Did CommunityCARE end as of January 1, 2011? Transition Are providers still permitted to provide services to CommunityCARE members? Effective January 1, 2011, DHH transitioned the Primary Care Case Management Program (PCCM) known as CommunityCARE into an enhanced version known as., which includes Pay for Performance (P4P) incentives, was established through an emergency rule published in late December 2010 (LAC 50:I , , 2917 and 2919). As of January 1, 2011, CommunityCARE has transitioned to. As part of the transition, both CommunityCARE PCPs and CommunityCARE enrollees were moved into, with linkages intact. Therefore, PCPs are permitted to provide services to those (previously CommunityCARE) enrollees on their CP If PCPs wish to continue participation in, they should complete an attestation stating their intent and submit it to DHH by January 31, If PCPs do not wish to participate in, they need to send written notification IMMEDIATELY to DHH so that enrollees linked to them have an opportunity to select a new PCP by February Transition How do I let DHH know I do NOT want to participate in? As of January 1, 2011, all CommunityCARE PCPs were transitioned to with their active linkages intact. If providers do not wish to remain in CommunityCARE 2.0, they must send written notification to DHH immediately so that enrollees can be given the opportunity to select a new PCP

2 by February Written notification can be sent to the following address: Automated Health Systems (AHS) Siegen Lane Building 3, Suites B&C Baton Rouge, LA Fax: (225) Transition How do I let DHH know that I do want to participate in? Transition Should providers stop seeing CommunityCARE members until they have completed the attestation and are officially enrolled in CC 2.0? Transition Is there a form I need to use to attest my intent to remain a provider? Where can I find this form? Coordinated Care Networks What happens to when Coordinated Care Networks are implemented? Enrollees Will the enrollee see any changes in benefits or services? As of January 1, 2011, all CommunityCARE PCPs were transitioned to with their active linkages intact. If PCPs wish to continue with, they must provide attestation of their intent to remain in the program by January 31, No. As of January 1, 2011, all CommunityCARE PCPs were transitioned to with their active linkages intact. If PCPs wish to continue with, they must provide attestation of their intent to remain in the program by January 31, Yes. DHH has created an official attestation form for PCPs to submit their intent to remain a PCP. The form was faxed to PCPs and is posted on DHH considers and the P4P measures a bridge to the next phase of coordinating care for Medicaid enrollees in Louisiana. As Coordinated Care Networks are implemented, will be phased out. DHH expects enrollees will experience better coordination of care and greater access to care (e.g. extended office hours)

3 which is anticipated to reduce emergency room utilization. Enrollees When will the other populations (SSI, Native Americans, and individuals in foster care, out-of-home placement and adoption assistance) be added to? There is no change in the enrollee benefit package. These populations will be added to the program as soon as Federal requirements for advance notice can be met. What is the definition of the Full Time Equivalent (FTE) for? What hours qualify as extended hours in the P4P criteria? DHH has defined the Full Time Equivalent (FTE) for as follows: Physician Full Time Equivalent (FTE) is one who provides direct patient care at a single location at least 32 hours a week (formerly required to work 20 hours per week, is enrolled as a Primary care Provider sole proprietor or as a member of a physician group practice and is eligible to have up to 2,500 linkages. A nurse practitioner (NP) is one who provides direct patient care at a single physician or physician group practice location at least 32 hours a week and is eligible to have up to 1,000 linkages. A physician assistant is one who provides direct patient care at a single physician or physician group practice location at least 32 hours a week and is eligible to have up to 1,000 linkages. An independent nurse practitioner is one who provides direct patient care at a single location at least 32 hours a week, is eligible to have up to 1,000 linkages and is enrolled as a Primary Care Provider Any hours before 8 a.m. or after 5 p.m. and all times on Saturday or Sunday meet the extended hour s requirement.

4 Can Nurse Practitioners be providers in their own right now or do the MD supervisory requirements still stand? If an individual physician has two office locations, there is some concern that they may be unable to meet the 32 hour FTE requirement. In this case, will they be unable to accept Medicaid patients at one of the offices? Are any hours over the mandatory 32 FTE considered extended? Nurse Practitioners may enroll as a Primary Care Provider practice but the Nurse Practitioner scope of practice requires an agreement with a physician. Yes. It is possible this may happen. Extended hours only include those times where work is performed before 8 a.m. or after 5 p.m. and all times on Saturday or Sunday. Are extended hours mandatory? Yes. Extended hours (before 8 a.m. after 5 p.m. and on Saturday and Sunday) are mandatory requirements for practices with 5,000 or more linkages. PCPs with fewer than 5,000 enrollees linked may receive Pay for Performance reimbursement for providing care during extended hours but are not mandated to offer extended hours. Can you provide some practical examples of how the FTE policy will be applied given the attestation timeline and the March 31, 2011 compliance deadline? If two or more physicians make up a site and each physician works 20 hours now and they have 5,000 linkages, they must submit an attestation by January 31, 2011, of their intent to work 32 hours per physician by March 31, 2011 to retain the number of linkages and participate in P4P. If a physician group practices with two FTE who have more than 5,000 linkages they will not receive any additional linkages until they are below 5,000 linkages.

5 If two or more physicians (a group practice) make up a site and each physician works less than 32 hours, but a total of 32 hours of direct care is in place by March 31, 2011 at the location, they may continue to participate in but they cannot participate in P4P. If one PCP works 32 hours per week and one works 20 hours per week, that site is considered on FTE and may be eligible for up to 2,500 linkages. KIDMED and Immunizations Is DHH doing away with subcontracting? DHH will continue to allow PCPs to subcontract for EPSDT. However, to incent PCPs to perform EPSDT screenings in the medical home rather than subcontract for them at a separate location, $.25 PMPM for enrollees under age 21 will be paid to PCPs who do not subcontract for EPSDT KIDMED and Immunizations How does the Louisiana Immunization Network for Kids System fit into the program? screenings. Primary Care Providers wishing to participate in have to be enrolled in the Louisiana Immunization Network for Kids System (LINKS) by March 31, 2011 and must indicate their intent to do so by attestation by January 31, Although the name indicates kids, the site maintains information for adults so this is a requirement for all PCPs regardless of the age restrictions of their practices. The website provides information about the LINKS and enrolling at KIDMED and Immunizations Is a provider still permitted to subcontract KIDMED services? Yes, but the provider will not receive the EPSDT P4P incentive. DHH is incentivizing coordination of care through a medical home by paying those who provide the EPSDT services themselves.

6 KIDMED and Immunizations If a provider does not comply with the P4P requirements in, are they forfeiting the extra PMPM payment? Yes. That is correct. KIDMED and Immunizations Pay For Performance Pay for Performance In a physician or clinic group, can one site subcontract with another site/member of the group to handle KIDMED screenings or does the site have to perform the screenings on site to receive the P4P? Is a provider required to participate in the P4P measures in order to participate in? What are the measures and reimbursement rates for the Pay for Performance portion of CommunityCARE 2.0? The intent is to support the medical home and have all medical records in one site and all prevention and medical treatment in one site. For that reason, the distribution of services and screenings to other sites is not allowed to receive the P4P portion. No, the provider must meet the requirements to participate in but does not have to participate in the P4P.They will still receive the base fee. Rate of low-level emergency room utilization (claim codes [Level 1] and [Level 2]) - $0.75 maximum. $0.75 per enrollee per month if emergency room utilization by linked enrollees is in the lowest quartile (below 25 th percentile) of the utilization of ER levels 1 and 2 for the reporting quarter. $0.50 per enrollee per month if emergency room utilization by linked enrollees is in 2 nd quartile (26-50 th percentile) of the utilization of ER levels 1 and 2 for the reporting quarter. $0.25 per enrollee per month if emergency room utilization by linked enrollees is in 3 rd quartile (51-75 th percentile) of the utilization for ER levels 1 and 2 for the reporting quarter. For the first six months of the program, a PCP with a ranking in the third

7 TOPIC QUESTION ANSWER quartile will be eligible for payment. After six months, PCPs in the third quartile will receive no payments. Compliance will be monitored through claims data. Extended office hours for scheduled appointments - $0.75 per enrollee per month. Minimum of 6 hours per week if more than 5,000 linkages. Minimum of 4 hours per week if 2,000-5,000 linkages. Minimum of 2 hours per week if fewer than 2,000 linkages. NCQA PCMH Level I Recognition or Joint Commission on Accreditation of Healthcare Organization (JCAHO) - $0.50 per enrollee per month. Verification will be conducted by the submission of a practice s NCQA Patient-Centered Medical Home recognition certification or JCAHO Primary Care Home Accreditation. During the transition of CommunityCARE to and to allow an opportunity and time for PCPs to attain NCQA recognition or JCAHO accreditation, this payment will be made for the first three quarters of the program on attestation and documentation that the PCP is pursuing NCQA recognition/jcaho accreditation. Effective with the quarter beginning October 1, 2011, payment will be contingent on providing verification of NCQA recognition/ JCAHO accreditation no later than the last month of the quarter. Requirements for enrollees under the age of 21 only.

8 The PCP must perform EPSDT screenings rather than subcontracting the screenings. The PCP must provide all required screenings at the PCP s site - $0.25 per enrollee per month. Program Requirements What are the basic program requirements to participate in? Current immunization pay-for-performance initiative has been moved into. Requirements for participation in the immunization P4P will not change from those currently in place. Maximum per enrollee per month is $1.00 if at least 90% of children are up-to-date according to LINKS. The following requirements must be met for a provider to qualify for the base management fee in : Must be a physician (internal medicine, pediatrician, family medicine, general medicine, or OB/GYN); physician clinic; federally qualified health center (FQHC); rural health clinic (RHC); or nurse practitioner. Must participate in the LINKS electronic immunization database program. Must make direct medical care available in the office for at least 32 hours per week at a single location. Must have Internet access, provide an address and conduct administrative transactions (submitting and receiving information) with DHH electronically. Providers may request a 12-month waiver of the electronic billing requirement with a statement of intent to develop capacity. Must sign an attestation documenting agreement with the conditions above and asserting that all of the conditions are being met in their daily operations.

9 Practices with 5,000 or more linkages must have extended hours for scheduling routine, non-urgent and urgent care appointments of at least 6 hours per week, which may be spread over weekdays or weekend days or a combination (see the Pay for Performance measure for the time frame in which extended hours must be implemented). The PCP may continue to bill for the $14 fee differential currently available through the fee-forservice system for seeing a patient during extended time periods. Program Requirements If a CommunityCARE provider does not currently meet all requirements to participate in, are there exceptions to the requirements for the transition period? DHH recognizes the need for a transition period to meet requirements. Details on transition times are indicated below: LINKS requirement - the PCP must attest their intent to comply with this requirement by January 31, 2011, and installation and participation must be in place by March 31, 2011 for the continuation of the monthly payment and eligibility to participate in the Program. 32 hours per week requirement - the PCP must attest their intent to implement the required 32-work week hours by January 31, 2011, and the 32-hours work week must be in place by March 31, 2011 for the monthly payment to be made. If the PCP does not provide the required 32 hours per week as of March 31, 2011, the PCP shall be deemed in non-compliance of the participation requirements and shall be removed from the program, and all linkages will be terminated. The base management fee will only be paid after this period if the 32 work hours per week have been verified. Electronic Billing - Providers may request a 12-month

10 waiver of the electronic billing requirement with a statement of intent to develop capacity. Medical home certification the PCP must attest their intent to pursue medical home certification by January 31, 2011, and must provide verification by December Program Requirements My practice sees very few Medicaid patients. How will this program change affect me? 15, PCPs enrolled as CommunityCARE PCPs at the time of transition to with fewer than 100 enrollees may participate in the program, but will receive the base management fee only and are not eligible to participate in the enhanced pay-for-performance pool. New PCPs who have not previously participated in CommunityCARE are exempt from this requirement in the first 12 months of their entry into the Program and may participate in the payfor-performance portion of the program in their first year of enrollment, regardless of the number of linkages. Referrals Is it necessary for FQHCs, urgent care clinics or retail convenience clinics to request a referral when they see PCPs CC 2.0 enrollees? No, FQHCs, urgent care clinics and retail convenience clinics do not need referrals from a PCP. Training and Resources Training and Resources Are there any resources for providers wishing to learn more about Primary Care Home Accreditation through the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)? Are there any resources for providers wishing to work toward NCQA Level 1 Recognition? Yes. The JCAHO can be reached by phone at (630) Providers can all visit the JCAHO web site at The site includes a detailed contact listing that provides direct phone numbes and addresses for JCAHO staff. Yes. Providers wishing to work on their NCQA Level 1 Recognition may contact NCQA by ppc-pcmh@ncqa.org or by calling (888) , Monday through Friday, 8:30 a.m. 5 p.m. (Eastern Time), or visit the NCQA Web site at

11 In addition, providers can access the resources provided by the Louisiana Health Care Quality Forum. Visit or call (225) for more information. Training and Resources Training and Resources When will the manual and training guides for be available? When will quality profiles and utilization reports be available? Those documents are currently being updated and will be posted online at and when completed. Quality profiles and manuals are available now at Trained staff will be in the field beginning January 18, 2011 to begin contacting practice sites. Provider utilization reports to be posted by January 31, 2011 at