Md. Code Regs. 10.67.04.03-2

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.67.04.03-2 - HealthChoice Population Health Incentive Program (PHIP)

A. Effective January 1, 2022, the Department shall establish the HealthChoice Population Health Incentive Program (PHIP).

B. An MCO may be eligible for an incentive payment for the following performance measures:

(1) Ambulatory care visits for Supplemental Security Income (SSI) adults;

(2) Ambulatory care visits for Supplemental Security Income (SSI) children;

(3) HEDIS asthma medication ratio;

(4) Hemoglobin A1c control for patients with diabetes - poor control (>9.0%);

(5) Lead screening measures:

(a) Lead screening measure for children 12-23 months old; and

(b) HEDIS lead screening in children;

(6) HEDIS postpartum care;

(7) HEDIS risk of continued opioid use->=31 days covered; and

(8) HEDIS timeliness of prenatal care.

C. Each measure identified in §B of this regulation shall be valued equally at a proportional share of available incentive funds, except for measures §B(5)(a) and (b), which are each valued at half of the available incentive funds relative to one of the other measures.

D. There shall be two rounds of potential incentive payments an MCO may earn.

E. Subject to budget approval, total PHIP funding shall be determined prior to the measurement year and included in the MCO contract.

F. All PHIP payments shall be funded independently from and outside of MCO capitation payments during a given calendar year.

G. Each MCO shall be eligible for no more than 1 percent of the plan's measurement year capitation payments, excluding supplemental payments outside of capitation, as total payment from round one and round two.

H. If the Department determines that the score for any measure identified in §B of this regulation may not be comparable to the previous year's score due to alterations in measure specifications or other factors, the Department may exclude the measure from the PHIP and adjust the incentive valuation in accordance with the remaining performance measures.

I. Round One Incentives.

(1) An MCO may earn two types of incentives in round one:

(a) A performance incentive payment; and

(b) An improvement incentive payment.

(2) If an MCO does not report a performance measure or an MCO has a performance score of 0 percent, then the MCO is awarded no performance or improvement incentive payments for this measure.

(3) Performance Incentive Payments for Round One.

(a) Performance incentive payments shall be based on the following categories for each performance measure:

(i) Superlative performance, meaning the performance measure's score is at or above the 90^th percentile of HEDIS Medicaid performance nationwide during the measurement year, or estimated 90^th percentile among Maryland Health Choice MCO performance for non-HEDIS performance measures;

(ii) Very strong performance, meaning the performance measure's score is between the 75^th and 89^th percentiles, inclusive, of HEDIS Medicaid performance nationwide during the measurement year, or between the estimated 75^th and 89^th percentiles, inclusive, among Maryland HealthChoice MCO performance for non-HEDIS performance measures; or

(iii) Strong performance, meaning the performance measure's score is between the 50^th and 74^th percentiles, inclusive, of HEDIS Medicaid performance nationwide during the measurement year, or between the estimated 50^th and 74^th percentiles, inclusive, among Maryland HealthChoice MCO performance for non-HEDIS performance measures.

(b) Payments for round one performance incentives shall be allocated as follows:

(i) For superlative performance, an MCO may earn 100 percent of the incentive allocation for the performance measure;

(ii) For very strong performance, an MCO may earn 66.6 percent of the incentive allocation for the performance measure;

(iii) For strong performance, an MCO may earn 33.3 percent of the incentive allocation for the performance measure; and

(iv) Any MCO earning a performance measure score below the 50th percentile of HEDIS Medicaid performance nationwide during the measurement year on a HEDIS-based measure, or below the calculated 50th percentile among Maryland HealthChoice MCO performance for a non-HEDIS measure, shall be ineligible for a round one performance incentive payment.

(4) Round One Improvement Incentive Payments.

(a) An MCO may earn an improvement incentive payment for any performance measure if the following conditions are met:

(i) The MCO demonstrates improvement of at least 0.5 percentage points in the measure compared to the previous measurement year; and

(ii) The performance measure score is at or above the 50th percentile of HEDIS Medicaid performance nationwide on a HEDIS-based measure, or the 50th percentile of Maryland HealthChoice MCO performance for a non-HEDIS measure.

(b) An MCO earning a superlative performance incentive payment for a performance measure is ineligible for an improvement incentive payment for the same measure.

(c) For any performance measures in which a lower score indicates stronger performance, year-over-year improvement is demonstrated by a reduction in the score for that measure.

(d) If an MCO is missing or zero-valued for a performance measure in the previous year, then no improvement incentive will be awarded in the measurement year.

J. Round Two Incentive Payments.

(1) An MCO may qualify for payments under round two if the following conditions are met:

(a) The MCO earned above 80 percent of possible round one incentives; and

(b) The MCO did not have penalties applied during the measurement year for failure to meet the HEDIS MCO Performance Monitoring Policy included in the MCO contract.

(2) Any remaining funds that were unallocated during round one may be awarded to eligible MCOs in round two for a maximum incentive award of up to 1 percent of its total capitation payment during the PHIP measurement year, excluding supplemental payments outside of capitation.

(3) If any remaining funds that were unallocated during round one are not sufficient to settle all qualifying MCOs up to 1 percent of capitation in round two, then the leftover funds will be awarded proportionally among qualifying MCOs based on enrollment.

K. If additional funds remain after both round one and round two, the Department may, within its discretion, allocate the funding as follows:

(1) Make additional payments to MCOs that are below 1 percent of capitation based on improvement or performance; or

(2) Place remaining funds into a nonlapsing pool.

L. Incentives awarded under this regulation are not appealable under COMAR 10.67.10.

Md. Code Regs. 10.67.04.03-2

Regulations .03-2 amended effective 48:21 Md. R. 889, eff. 10/18/2021; amended effective 51:12 Md. R. 620, eff. 6/24/2024.