NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES
18-008 PHYSICIAN SERVICES FOR PATIENT-CENTERED MEDICAL HOME PILOT: This is a time-limited pilot as defined in Neb. Rev. Stat Sections 68-957 to 68-961. Participation is limited to the practices selected by the Department.
18-008.01 Definition of Patient-Centered Medical Home: Patient-Centered Medical Home means a health care delivery model in which a patient establishes an ongoing relationship with a physician in a physician-directed team. This team will provide comprehensive, accessible, and continuous evidence-based primary and preventive care, and coordinate the patient's health care needs across the health care system in order to improve quality, safety, access, and health outcomes in a cost effective manner.
Practices for participation in the pilot will be limited to General Practice, Internal Medicine, Family Practice, and Pediatrics.
18-008.01A Service Components: The medical home is comprised of the following components:
1. Care coordination: One or more Medical Home staff are dedicated to coordinating the care of the patients. Care is coordinated across all facets of the health care system. Information technology is utilized to support patient care.
2. Accessibility: The medical home offers access to care outside traditional business hours and utilizes systems of care for access to the team 24 hours/day, 7 days/week.
3. Patient Engagement: Patients are encouraged to take responsibility for their health care through a clear health plan, joint decision making, and patient education provided by the medical home.
4. Quality Improvement: Members of the medical home team assume responsibility for continuous quality improvement through the use of data and evidence-based best practices.
18-008.02 Provider Participation: Practices selected by the Department to participate in the Medical Home Pilot shall meet the standards listed in the medical home agreement.
18-008.03A Fee-for-Service (FFS): The Medical Home provider will be reimbursed for all allowable Medicaid services. Payment is made according to the Nebraska Medicaid Practitioner Fee Schedule as described in 471 NAC 18- 006.
18-008.03B Incentive Payment: The Medical Home provider will receive a per member per month and may receive an enhanced fee-for-service when certain standards are met.
18-008.03B1 Per Member Per Month (PMPM) Payment: For patient care coordination and administration expenses, the pilot Medical Home will receive an initial PMPM payment. This payment will begin once the agreement is signed; then the Medical Home must achieve minimum standards within six months. Once the minimum standards are met, the PMPM payment will be increased.
If the minimum standards are not met within six months, the PMPM payment will be suspended until the minimum standards have been met.
18-008.03B1a Client Attribution Method: The client will not be selecting a provider nor will s/he be assigned a provider by the Department. The determination of client assignment for the PMPM will be done through an attribution methodology that recognizes the client's choice of a provider as follows:
1. There will be a look-back at paid claims for the past 12 months for the Medical Home for selected Evaluation and Management and Preventive Visit codes for Established Patients.
2. If the client is currently Medicaid eligible, the Medical Home with the most visits with a specific client will receive the attribution and the PMPM payment and enhanced FFS (if applicable) for that client for the month. If there is a tie between pilot Medical Homes, the client will be attributed to the practice that provided care for the last/most recent visit in the 12-month period.
3. The attribution will be re-assessed on a monthly basis for a rolling twelve months (i.e. each month, the oldest month will be dropped and the newest month added).
4. PMPM payment will be paid retrospectively (example: on December 31st based on claims history, Medical Home A will receive an attribution of X number of clients and will be paid for that number of clients in January).
18-008.03B2 Enhanced Fee-for-Services (EFFS) Payment: Upon successful completion of minimum standards, the pilot Medical Home will have the option of continuing to transform the Medical Home to meet the advanced standards. Once the advanced standards are met, the Medical Home will receive an additional enhanced FFS payment on selected Evaluation and Management and Preventive Visit codes for Established Patients.
18-008.04 Billing: The allowable Medicaid services are billed under the Medical Home provider number on Form CMS-1500 or the standard electronic Health Care Claim: Professional Transaction (ASC C12N 837). The physician services are billed under appropriate CPT codes.
HCPCS/CPT procedure codes used by NMAP are listed in the Nebraska Medicaid Practitioner Fee Schedule (see 471-000-518).
18-008.04A Billing for Medical Home Pilot Per-Member-Per-Month (PMPM) and for Enhanced Fee-for-Services (EFFS): The PMPM and EFFS will be automatically processed by the Department. The Medical Home does not need to submit a separate claim for either.