Comprehensive Primary Care Plus (CPC+) is a five-year, multi-payer model that builds on the original CPC initiative (CPC Classic) to improve primary care. Participating primary care practices receive additional payment outside of the fee-for-service, including population-based care management fees for better coordination of patient care and the opportunity for performance-based incentives.

Review the CPC+ Participating Provider Training deck for an overview of the program.

Frequently Asked Questions

General Information

  • What is the purpose of CPC+? CMS is testing various payment and service delivery models that aim to achieve better care for patients, smarter spending and healthier communities. CMS believes this can be achieved through payment reform and practice transformation as primary care practices build capabilities and processes to deliver better care. Payment redesign offers greater cash flow and flexibility for primary care practices to deliver high-quality, whole-person, patient-centered care while lowering the use of unnecessary services that drive total costs of care.
  • What is the difference between CPC & CPC+? CPC+ replaced the CPC Classic program. CPC+ offers providers two separate participation tracks. The track dictates the care delivery capabilities practices will develop and the payment structure they will receive.
  • What are the benefits of CPC+? CPC Classic achieved gross savings and was nearly cost neutral, with positive quality results in its first year. These findings came earlier than expected in a model involving significant changes in the delivery of primary care. CPC+ looks to build on these results by offering two tracks with different payment options to better accommodate the diverse needs of primary care practices.
  • What are the different participation tracks and what is the difference between them? There are two different participation tracks. Both tracks will receive Care Coordination fees during the year. Both tracks will receive performance payments, if they meet Quality and Utilization metrics, after the completion of the first year.
    • Track One practices will continue to receive their regular fee-for-service payments for covered evaluation and management services.
    • Track Two practices will have a hybrid of fee-for-service and Comprehensive Primary Care Payment (CPCP) starting 1/1/2018. The hybrid value-based reimbursement will pay for covered evaluation and management services, but it allows flexibility for the care to be delivered outside of a traditional office visit. Over the next 3 years, there will be a phased approach applied toward further reduction in fee-for-service and building value-based payments.
  • How will primary care practices be encouraged and rewarded for their accountability for patient experience, clinical quality and utilization? We will pay a performance-based incentive retrospectively if they meet annual performance thresholds.

Participating Practices

  • Which payers are participating in CPC+? The major payers in Arkansas are QualChoice, Medicare, Medicaid, Arkansas Health and Wellness Solutions, HealthScope, Arkansas Superior Select and Arkansas Blue Cross Blue Shield. They are participating with the common goal to improve primary care to the patient.
  • How were practices selected to be in CPC+? Practices were selected through a competitive application process based on their:
    • use of health information technology
    • ability to demonstrate recognition of advanced primary care delivery by accreditation bodies
    • service to patients covered by participating payers
    • participation in practice transformation and improvement activities
    • diversity of geography, practice size and ownership structure
    • Are practices required to participate in CPC+ for the full five years? Practices that participate are expected to do so for the full five years. However, participation is voluntary and practices may withdraw without penalty.
    • What must a practice do to withdraw from CPC+? Practices are required to notify CMS at least 90 calendar days before the planned day of withdrawal. Practices may also notify QualChoice directly of their intent to withdraw from the program.

Training and Additional Information

  • What do CPC+ providers need to do? Extensive CMS resources are available, including live webinars and the CPC+ Connect internet tool. Visit Centers for Medicare and Medicaid Services CPC+.
  • Where can I get a copy of the QualChoice provider training document? The CPC+ Participating Provider training deck can be downloaded here.
  • Who can answer additional CPC+ questions? Email CPC+@qualchoice.com.

Member Rosters

  • How can a provider know which members are CPC+ members? QualChoice will post a list of your CPC+ members monthly on your Provider Home page in the My Account provider portal.
  • How can I make changes to my CPC+ member roster? QualChoice has 2 distinct sets of membership within CPC+:
    • Individual Metallic Health Plans – these members are required to actively select their PCP. If the member has selected a PCP in your clinic, then they are assigned to you. The member will remain on your attribution report until they inform us that they have selected a new PCP.
    • All other QualChoice non-self funded members are attributed to a PCP based on past claims history. They will be reattributed if their claims history indicates they have changed PCPs. 

Performance – Quality and Utilization Metrics

  • What are the performance thresholds? The performance thresholds are broken into two distinct components, on which QualChoice will pay performance-based incentives retrospectively:
  • Performance on clinical quality/patient experience is based on specific quality performance measures and Consumer Assessment of Healthcare Providers and Systems (CAHPS) metrics.
  • Performance on utilization is based on claims-based measures commonly used to determine total cost of care and measurable at the practice level [e.g., inpatient admissions and emergency department visits that are available in the Healthcare Effectiveness Data and Information Set (HEDIS)].
  • How is the risk adjustment of a practice population calculated? When a practice applies to CMS for CPC+ status and requests Track One or Track Two, they must provide Electronic Medical Records to help determine risk stratification.
  • Where are the metrics listed? Quality and utilization metrics can be found in your QualChoice CPC+ provider contract. A summary of these metrics is also available in the CPC+ Participating Provider training deck.
  • What are the targets for each measure?There are no fixed targets. The mean (mathematical average) has to be calculated for every performance metric, based on the data we receive. The goal is to perform above average (better than peers).
  • How are the quality metric thresholds calculated? Each quality metric will have an arithmetic mean of performance across all CPC+ practices. The goal is to have “above average” performance (better than the arithmetic mean—whether better means higher or lower) compared to other CPC+ practices. The quality threshold (to be eligible for performance incentives) is above-average performance relative to other CPC+ practices on all combined quality metrics. This means a practice may or may not perform above average on every single quality metric but may still achieve overall, combined above-average performance.
  • What do I need to achieve to earn a performance payment? Performance incentive payments to practices will be based on quality and utilization metric reports. Eligibility for performance payment requires above-average performance relative to other CPC+ practices on all combined quality metrics. This means that a practice may or may not perform above average on every single quality metric, but may still achieve overall combined above-average performance for quality and, therefore, will be eligible for performance payment. The performance on utilization metrics will then be considered and subject to the same methodology. 

Care Plans

  • What percent of members require submission of a care plan date? QualChoice requires care plan dates to be submitted on the top 10% of high risk members.
  • How do we determine which patients need care plans? The practice (not QualChoice) must identify their top 10% of highest risk/tier patients. Every practice may not have tier 4 or tier 5 (track 2 only) patients. The highest risk members will require care coordination as well.
  • What care plan information is required? At this time, we do not require specific information or format for care plans. We require only the dates when care plans were created or updated.
  • How do I submit care plan dates? Sign in to My Account at QualChoice.com. In the CPC+ section, follow the links to search members and submit care plan dates.
  • When are care plans submitted? Care plans must be submitted once every 6 months starting 4/1/17.

Payments

  • How will primary care practices be paid? A practice is paid depending on the track in which it participates. Participants in both tracks will receive Care Coordination fees and Performance payments in the first year. Both tracks will be paid:
    • Care Management Fee (CMF): a non-visit based, retrospective payment Per Member Per Month (PMPM). The amount is risk-adjusted for each practice to account for the intensity of care management services required for a practice’s specific population. Practices will use this enhanced, non-visit-based compensation to augment staffing and training in support of population health management and care coordination.
    • Performance-Based Incentive Payment: QualChoice will pay retrospectively and annually an incentive payment based on how well the practice performs on clinical quality measures and on utilization measures that drive total cost of care. The incentive payment will be based on both quality and utilization reports. Reporting data will be collected from claims and Category II CPT Codes (Non-billable codes). Each practice should have minimum of 50 attributed members captured on a quarterly Attribution report to qualify for performance incentive payment.
  • Track One Will be Paid: Fee-For-Service (FFS) from payers as usual throughout the five years.
  • Track Two Will be Paid: Reduced Fee-For-Service (FFS) and comprehensive primary care payments, beginning January 1, 2018. After 3 years, further reductions may apply to the payments in a phased approach.
  • Why do different payers pay different fees? Each payer determines their own financial support to practices, separately from that of normal fee-for-service.
  • When is the Care Management Fee PMPM paid and how much is the payment? Care management fees are paid quarterly. The payment is issued in the month following the end of a quarter. Your care management fees are outlined in your QualChoice CPC+ provider contract.
  • How will a provider recognize the care coordination payments on their Remittance Advice? CPC+ care coordination payments will be made through normal claims payment. Clinics will see a claim payment for assigned members under CPT code CPCP0. For example, the provider RA will show a claim for an assigned member for a date of service in April, May or June for CPT code CPCP0 with the assigned PMPM amount as the allowed amount. 
  • What is the timeline for Performance Incentive Payments? An annual performance incentive payment will be made to eligible practices during the quarter following the performance year.
  • How will the amount of the incentive bonus be determined? The amount of the payment will depend on the degree of variance from the average. In other words, the higher the practice performance above the average CPC+ practices, the higher the payment amount.

Performance Reports

  • How do CPC+ providers submit reports? Sign in to My Account at QualChoice.com to upload your reports beginning June 1, 2017.
  • What is the timeline for attribution and performance reports? CPC+ member rosters are published the first of each month. Performance reports will be published quarterly, starting in October 2017 when there is sufficient data for publication.

Portal

  • How do I sign in to the provider portal? Go to QualChoice.com and click the My Account link. On your Provider Home page, look for the CPC+ section at lower right.
  • How do I sign up to be a portal user? Download and complete the Provider Portal Administrator and User Access Forms