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Value-based programs

PCMH FAQs

Overview

What is the purpose of a PCMH?

A patient-centered medical home (PCMH) is a care team that manages the overall health and coordinates the care of a patient. The PCMH program is designed to assist primary care practices in transitioning to PCMHs through guidance and support, while rewarding them for high-quality, coordinated and efficient care.

Will other Arkansas Blue Cross and Blue Shield plans participate?

Health Advantage fully-insured plans, Arkansas Blue Cross and Blue Shield fully-insured plans and some self-insured plans began participation in 2015.  Medi-Pak Advantage HMO and PFFS plans will also participate in 2020.

Enrollment

Who is eligible to enroll as a PCMH?

Primary care providers (MD, DO, APRN, APN, NP, PA, CNS) that are credentialed with Arkansas Blue Cross and Blue Shield who practice in the following areas: family medicine, general practice, geriatrics, internal medicine, and pediatrics.

How does a practice enroll?

Enrollment is held each fall.  Practices who are interested in participating can email primarycare@arkbluecross.com.  A Primary Care Representative will provide instructions at the time of enrollment.

Will providers that do not enroll in PCMH be penalized?

No. The PCMH program is voluntary and will not affect your network participation.

Requirements

What does a PCMH practice have to do to receive per member per month (PMPM) payments?

The practice must be enrolled in the PCMH program, perform all required activities by their respective due dates, and meet the majority of quality metrics.  See the Arkansas Blue Cross PCMH Provider Manual or contact the Primary Care Department at primarycare@arkbluecross.com for more information. 

Practice support

What type of assistance can I expect?

Practices in the PCMH program will have a Primary Care Representative to guide them through the PCMH process.  Practices will have access to PCMH resources, webinars and training throughout the year.  The Primary Care representative will be available to answer questions, provide feedback or make site visits as necessary to help practices be successful.

There are two financial components to support Practices, care management fees and a performance based incentive.  Care management fees are calculated on a per member per month (PMPM) basis for all fully insured plans and some self-insured plans.  The performance based incentive (PBIP) began with the 2020 program year and is calculated on quality metrics, utilization, and patient experience of care.

Self-insured groups that participate in the PCMH program also pay care management fees and PBIP for their aligned membership.

What happens if a PCMH practice does not meet the requirements?

A PCMH practice that fails to complete practice activities or meet the majority of metrics by their respective deadlines must address their shortfalls or risk program suspension or termination. See the Arkansas Blue Cross and Blue Shield PCMH Provider Manual for more information regarding remediation.

If the number of aligned patients to my clinic changes, will my payment amount change?

For monthly care management fees, yes, the total payment may change monthly based on the number of aligned patients.  For the PBIP, because the payment is paid once, at the end of each program year, the amount will not change.

High priority beneficiary list

How do I choose my high priority patients?

Your list of Arkansas Blue Cross Plan patients will load onto the PCMH Portal beginning late March and you will choose your top 10% of high-risk patients from that list. Arkansas Blue Cross will provide a numeric risk score that practices can use, or the practice my select their high priority patients based on their own knowledge of the individuals.  Practices will need to identify the Arkansas Blue Cross Plan high-risk patients by the deadline indicated on the PCMH Portal in AHIN.

After choosing and submitting my top 10% high priority patients, what if my number of attributed patients changes? Do I need to choose more to make up the percentage?

No. Those patients chosen on the high priority list by the due date will remain for the program year. You will not need to adjust due to caseload changes.

Metrics tracked

Will I have to meet all of the metric targets for my Arkansas Blue Cross Plan patients during the program year?

Participating clinics must meet activities and the majority of quality metrics according to the Arkansas Blue Cross PCMH provider manual, which can be located on the PCMH Portal on AHIN.

Reports

Will Arkansas Blue Cross and Blue Shield provide clinic reports?

Yes. Monthly reports will be available through the care management portal on  AHIN.