WYOMING MEDICAID PCMH Summit January 24, 2019

1. WYOMING MEDICAID PCMH Summit January 24, 2019 Dr. James Bush - Wyoming Medicaid Medical Officer

2. PCMH VALUE • Earn higher reimbursement: More than 100 payers and other organizations offer either enhanced reimbursements for recognized clinicians or support for practices to become NCQA recognized. • Succeed in Medicare Access & CHIP Reauthorization Act (MACRA): Clinicians recognized by NCQA PCMH automatically get full credit in the MIPS Improvement Activities category and will likely do well in other Merit-based Incentive Payment System (MIPS) categories. • Focus on Patient Care: One aspect of the PCMH model is to ensure each team member operates. at the highest level of their knowledge, skills, abilities and license within their assigned roles and responsibilities. NCQA

3. NCQA & MACRA MIPS Commit Succeed Transform 1. Practice submits initial documentation and checks in with its evaluator. 2. Practice submits additional documentation and checks in with its Evaluator. 3. Practice submits final documentation to complete submission and begin NCQA evaluation process. 4. Practice earns NCQA Recognition. 1. Practice completes an online guided assessment. 2. Practice works with an NCQA representative to develop an evaluation schedule. 3. Practice works with NCQA representative to identify support and education for transformation. 4. New NCQA PCMH online education resources support the transformation process. 1. Practice is prepared for new payment environment (value-based payment, MACRA MIPS/APMs). 2. Practice demonstrates continued readiness and high quality performance through annual reporting with NCQA. NCQA

4. PCMH VALUE MIPS: • If you decide to participate in traditional Medicare, you may earn a performance-based payment adjustment through MIPS • Provides clinicians with flexibility to choose the activities and measures that are most meaningful to their practice • Reporting standards align with aAPMs wherever possible Categories: • Quality • Cost • Improvement Activities • Advancing Care Information

5. HOW CAN PCMH HELP? Remember that Improvement Activity? • Participants in a certified PCMH receive FULL CREDIT for the Improvement Activity category! • FULL CREDIT is for the entire TIN (reporting as a group) regardless of the number of providers participating in the PCMH Quality Measure Alignment • Wyoming Medicaid has selected measures which align with the MIPS program

6. QUALITY MEASURES Wyoming Medicaid PCMH Program is in the process of configuring all 64 electronic Clinical Quality Measures certified for EHR use: • Which measures does your EHR support • Which measures make sense to your practice, speciality or patient demographic • Use the same set of measures for MIPS and for PCMH! Does your EHR track and trend data in a simple fashion? If no, use the Wyoming Medicaid dashboard to view your results and progress! https://wyqccp.htscqm.net/

7. PCMH - MAXIMIZE THE IMPACT IN MIPS • Align Measures • Using PCMH resources to track and trend data • Identify measures which have the largest opportunity for improvement • Monitoring the effect of improvement activities

8. WY MEDICAID PCMH 2019 REQUIREMENTS • For 2019 we are requiring all PCMHs to report on a minimum of 12 CQMs. We do have all 50 CQMs in the portal. • CQMs will need to be entered into the PCMH portal by the 20th day, after the end of the quarter. If they are not entered by that time you will not be eligible for payment. • A minimum of 20 CCDs (or 20% of Medicaid volume, whichever is lower) will need to be pulled and reviewed monthly, however we would recommend that you pull and review a CCD for all your Medicaid patients. • Formal recognition in 2019 is not required for new participating clinics, but we do ask that you be in the process of recognition. • You will need to be a recognized practice for program year 2020.

9. Payments and Billing PAYMENT • $6 – NCQA recognized or equivalent recognition (URAC & JCAHO) • $3 - In process of obtaining NCQA or equivalent status (must be obtained within 1 year of joining program beginning January 1st, 2020). Procedure Codes: • S0280 – 1st time billing only • S0281 – Sequential billing – medical home program, comprehensive care coordination and planning, maintenance of plan. • Z78.9 - This is the diagnosis code to be used each and every time you bill Medicaid. Note: Only bill PMPM for clients where you are their primary care physician. If the client is seen by more than one physician within the 365 days, it is the responsibility of the providers to determine who the PCMH is and to bill accordingly.

10. Questions?