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Comprehensive Primary Care
Extensive list of common questions for the CPC Program.
Comprehensive Primary Care

Ohio Comprehensive Primary Care (Ohio CPC) is Ohio Medicaid’s patient-centered medical home (PCMH) program: a team-based care delivery model led by a primary care practice that comprehensively manages a patient’s health needs. The aim is to empower practices to deliver the best care possible to their patients, both improving quality of care and lowering costs.

CPC for Kids is a component of the CPC program. The focus is to improve wellness and close equity gaps for children statewide, using the Ohio CPC program as a foundation.

Fee-for-service (FFS) claims data and encounter claims data received by the managed care plans is used for CPC attribution and all reporting. Each quarter practices receive quarterly practice reports showing performance across all payers plus attribution and payment files showing all attributed members for patient outreach. All reports are posted to the MITS Secure Provider Portal.

There are financial and non-financial benefits to participating. Financial benefits: Participating practices may be eligible for two payment streams in addition to existing payment arrangements. A per-member-per-month (PMPM) payment supports activities that are required. Additionally, some practices may be eligible for shared savings payments for achieving total cost of care savings and meeting pre-determined quality targets.
Non-financial benefits: Joining the CPC program means recognition as a state-designated CPC practice, which can help attract new members, as well as access to data and reporting that will provide the actionable, timely information that practices need to make better decisions about outreach, care, and referrals.

Per policy (OAC 5160-19-02) providers must meet all of the activity requirements, 50% of applicable clinical quality metrics, and 50% of applicable efficiency metrics to qualify for both PMPM and shared savings payments. If the activity requirements are not met upon evaluation, payment under the rule terminates. If the efficiency and clinical quality requirements are not met, a warning will be issued. After two consecutive warnings, payment will be terminated.

Practices that average over 5,000 attributed Medicaid members over the performance year may be eligible to receive shared savings payments for having low total cost of care. Shared savings payments are calculated and delivered in the following performance year. Details on the shared savings methodology can be found at CPC Payments.

All participating practices will be paid per-member-per-month (PMPM) payments based on their quarterly attributed members. Practices may also be eligible for a shared savings payment for having low total cost of care. More details about the PMPM pricing and shared savings methodology can be found at: CPC Payments.

 

Practices enrolled in CPC for Kids must agree to passing 50% of the CPC for Kids pediatric-focused metrics. Find additional details at CPC for Kids.

Members are attributed based on fee-for service (FFS) and Medicaid managed care claims data. Certain exclusions and look back periods apply. Details to the attribution logic can be found at ODM Primary Care Provider Data Submission Specifications.

There are three main requirements that practices must agree to, in order to participate: 1) attesting to meeting a set of activity requirements, 2) a commitment to sharing data with payers and ODM, and 3) participating in learning activities as determined by ODM. Practices are also assessed against clinical quality and efficiency requirement metrics.

Practices that are eligible to enroll in the CPC program may also be eligible to enroll in the CPC for Kids program. Practices cannot opt-in to the CPC for Kids component unless participating in CPC. Participation in CPC for Kids is voluntary. The practice must have at least 150 claims-based pediatric attributed members at the time of enrollment as determined by ODM.

Practices who opt-in to CPC for Kids will receive an enhanced $1.00 for each pediatric attributed member. Practices may also be eligible for a bonus annual lump-sum payment based on performance.

Per policy (OAC 5160-19-01), practices must meet one of the following: (1) have at least 500 claims-based attributed members at the time of enrollment as determined by ODM Medicaid members; (2) have at least 150 claims-based attributed members at the time of enrollment as determined by ODM and attest to being part of a practice partnership under a convener practice. Practices who are found eligible by ODM will receive an invitation to participate. Open enrollment occurs every fall for the following program year.