Making Care Primary (MCP) Model Frequently Asked Questions

FAQ Topics:

• General
• Eligibility & Participation
• Quality
• Stakeholder Engagement & Learning
• Multi-Payer Alignment & Payment
• Care Delivery
• Specialty
   

General

1. How is this model different from the Primary Care First (PCF) Model Options?
   
   PCF tests the impact of providing prospective payment to advanced primary care practices and rewarding them for taking accountability for decreased hospital utilization. Making Care Primary (MCP) is focused on supporting less experienced primary care practices and organizations by helping them build advanced care delivery capabilities, foster coordination with specialty partners and, over time, assume prospective payments and accountability for cost and quality outcomes. MCP is built on the framework and priorities outlined in the CMS Innovation Center’s Strategy Refresh as well as the National Academies of Science Engineering and Medicine (NASEM) report on implementing high-quality primary care, both released in 2021.
    
2. What are the key differences between this initiative and ACO REACH?
   
   MCP is geared towards smaller, independent organizations that want to participate in value-based care independently (not as part of a broader entity). The model is designed to provide a progressive pathway to value-based payment, through three tracks that increase in care delivery and payment advancement over time. Making Care Primary has a different incentive structure, rewarding performance on multiple measures, one of which is cost-related, whereas ACO payment incentives are based on the amount of shared savings they achieved during the performance year.  

Eligibility & Participation

1. Can we move to the next Track before 2 years have passed?
   
   Participants that enter the MCP Model in Tracks 1 or 2 are required to remain in their assigned Track for 2.5 years, and then will transition to the next Track. Thus, in 2027, Participants that enter Track 1 will transition to Track 2 and Participants that enter Track 2 will transition to Track 3. Participants that enter Track 3 at the start of the model will remain in Track 3 for the duration of the model.
    

2. My practice’s beneficiary attribution looks too low. How was this calculated?
   
   Every quarter, CMS uses a two-step process to determine attribution to MCP. First, we look to see if Medicare beneficiaries have voluntarily aligned/selected a primary care clinician on Medicare.gov ahead of the specified cut-off date for each quarter. If so, the beneficiary is attributed to their selected clinician. If not, CMS relies upon claims to determine patient attribution. We examine claims submitted during a specified "look back period" and determine whether the beneficiary has had an eligible Annual Wellness Visit or Welcome to Medicare visit during that period. If so, we attribute the beneficiary to the primary care clinician that provided the most recent of these visits. If not, we attribute to the clinician that has provided a plurality of eligible primary care services during the lookback period. You can find more details and our full methodology in our Payment and Attribution Methodology Paper (PDF).

   The estimated number of attributed beneficiaries for Q1 2024 that was provided in applicant acceptance letters was determined using a lookback period that ranges from October 2021 - September 2023. Actual attribution for MCP participation in Q3 2024 is based on a lookback period of April 2022 - March 2024.
    

3. I was accepted into MCP, but my acceptance letter says that I have fewer than 125 beneficiaries. Am I still able to participate in MCP?
   
   CMS accepted primary care organizations with fewer than 125 attributed beneficiaries into MCP, and these primary care organizations can sign the Participation Agreement. These participants are required to accrue a minimum of 125 attributed beneficiaries by November 1, 2024, to remain in the model. Please refer to our Payment and Attribution Methodology Paper (PDF) for more information on how eligible beneficiaries are attributed to MCP participants.
    
4. The Change Healthcare cyber attack has disrupted my ability to submit Medicare claims during Q1 2024. How does CMS plan to account for this disruption when determining my attribution and payment rates?
   
   CMS is aware that some prospective MCP participants have experienced claims disruptions due to the Change Healthcare cyber attack. We are conducting analyses to determine how to account for these effects in our methodologies and will share more information as it becomes available.
    
5. Which states were selected for MCP and why were they chosen?
   
   Eight states were selected for MCP: Colorado, North Carolina, New Jersey, New Mexico, New York, Minnesota, Massachusetts, and Washington. CMS selected states for model testing based on several factors, including the ability to align with state Medicaid agencies, geographic diversity, health equity opportunity, population, current CMS Innovation Center footprint, and generalizability to the rest of the Medicare population for model evaluation. States where MCP will launch are working with CMS to align on areas such as quality measurement, data sharing and learning supports, and moving away from Fee-for-Service payment.
    
6. When will the model be an option for states who aren’t one of the eight original participants?
   
   MCP operates in eight states. We are not planning to expand to additional states at this time, but CMS will continue to evaluate the model and may reassess based on initial program experience.
    
7. How do we know which Track to apply for?
   
   Applicants should select the Track that best fits their readiness for the care delivery requirements and payment mechanisms. More information on the Tracks can be found in the Request for Applications (PDF).
    
8. Can Federally Qualified Health Centers (FQHCs) participate? If so, can FQHCs pool resources in this model to build and/or share resources and care coordination?
   
   FQHCs are eligible to apply to participate in MCP. A full list of eligibility criteria can be found in the Request for Applications (PDF). Accepted FQHCs and other participating organizations will be expected to independently meet all of the requirements of the model, however, FQHCs are welcome to work together to share lessons learned in order to meet the model’s goals. Each TIN will be considered a separate Participant.
    
9. How does the value-based payment process work with Tribes’ Encounter rates?  Is it an additional payment above the Encounter rate?
   
   Indian Health Program participants that bill the Physician Fee Schedule (PFS) for professional services will be provided Prospective Primary Care Payments (PPCPs) that are based on the PFS, similar to other participants that bill the PFS. Enhanced Services Payments (ESPs) will be provided to all MCP participants in place of the chronic care management (CCM) services they currently bill for. They should continue to bill their All-Inclusive encounter rate for applicable outpatient services.
    
10. Can practices that are in PCF and the Shared Savings Program (SSP) participate in this model as well? Are we able to join the model and later go back to an SSP ACO?
    
    PCF practices and ACO REACH Participant Providers who are in the program as of 5/31/23 are not eligible to join MCP. SSP practices are eligible to join MCP but may not concurrently participate in MCP and SSP. MCP will allow overlap between SSP and MCP from 7/1/24-12/31/24, but the practice will need to withdraw from SSP before PY25. Any MCP participant that was in a two-sided risk arrangement under SSP will not qualify for Track 1, because it is reserved for practices without prior experience in performance-based risk. MCP is a voluntary model and participants may withdraw subject to the terms of the Participation Agreement. Participants who withdraw prior to entering Track 3 may be required to repay all Upfront Infrastructure Payments received. After terminating their participation in MCP, a participant may join or re-join an SSP ACO subject to their meeting necessary SSP deadlines and criteria.
     
11. Does MCP count as an Advanced Alternative Payment Model and exempt participants from Merit-based Incentive Payment System (MIPS) reporting?
    
    CMS expects that certain components of MCP will qualify as Advanced Alternative Payment Models (APMs). The financial risk standards applied in making this determination with respect to MCP are the standards specific to medical home models. CMS expects that all Tracks in MCP will meet the criteria under 42 C.F.R. § 414.1367b for being a Merit-based Incentive Payment System (MIPS) APM in performance year 2 and all subsequent performance years, subject to annual APM determinations; however, only Tracks 2 and 3 are expected to be classified as Advanced APMs. Any MIPS eligible clinicians who are included on the MCP Clinician List will be eligible for scoring as part of a MIPS APM Entity, and for reporting through the APM Performance Pathway described at 42 § C.F.R. 414.1367. Participants with MIPS-eligible clinicians who are either Partial Qualifying Participants (QPs) that elect to report to MIPS, or who are neither Qualifying APM participants (QPs) nor Partial QPs, may be MIPS eligible.
     
12. Would entities with value-based purchasing (VBP) experience in Medicaid but not Medicare be eligible for Track 1
    
    Track 1 of the MCP Model is reserved for entities with no prior experience in programs listed in Request for Applications (PDF), Section 2A- Application and Applicant Eligibility Criteria. This list of programs does not include Medicaid value-based purchasing programs. 
     
13. Can Primary Care Associations (PCAs) participate?  What about a health center-controlled network (HCCN)?
    
    PCAs and HCCNs themselves are not eligible to apply and participate in the model. PCAs and HCCNs may support FQHCs in applying to and participating in the MCP Model.
     
14. Is CMS thinking at all about pediatrics in the MCP or will the focus with state agency involvement be on dual-eligibles?
    
    Making Care Primary is a Medicare-based model. Primary care clinicians with pediatrics as their specialty will be eligible to participate as a clinician with an MCP participant if they meet eligibility requirements listed in the. Additionally, payers aligned with MCP, including Medicaid, may choose to include program elements specific to pediatric patient populations. Beneficiaries enrolled in both traditional Medicare and Medicaid are eligible for MCP, provided they are not served by Medicare-Medicaid Plans as part of the Financial Alignment Initiative, which is a demonstration running in some MCP states. 

Quality

1. What is the threshold for Emergency Department Utilization (EDU) Continuous Improvement (CI)?
   
   For EDU Continuous Improvement (CI), a participant must improve on the prior year's score by 3% (relative to their own score) to earn half credit for the measure, or 5% (relative to their own score) to earn full credit for the measure.
    
2. Are model participants able to use third party vendor surveys if they are already in place? If we already contract with a patient survey vendor, how do we find out if they are approved by CMS?
   
   CMS will be releasing more information on how vendors can apply to become CMS-approved survey vendors for administering the Person-Centered Primary Care Measure (PCPCM) for MCP. If feasible, we aim to allow practices to reduce cost and burden by using their existing contracted survey vendors. The survey vendor will need to follow the fielding guidance and business requirements CMS communicates for PCPCM implementation.
    
3. Is there a template for the eCQM and CQM?
   
   For preliminary information about the quality measures that participants in the Making Care Primary (MCP) Model will be required to submit, please refer to the MCP Request for Applications (PDF). For more information on the measure specifications, please refer to the eCQI Resource Center for the eCQMs and CQMs, and search by eCQM Title or CMSID.
   
   Please see the QRDA page on the eCQI Resource Center for all QRDA-related information. This page includes applicable QRDA III documents including the CMS QRDA III Implementation Guide for Eligible Clinicians and Eligible Professionals, the CMS QRDA III Schematrons and Sample Files for Eligible Clinicians and Eligible Professionals, and any published addendums for each performance period. This information is updated annually. Note that the current versions of these files do not yet include Making Care Primary-specific information.
    
4. How does CMS find the benchmark data to compare participants’ performance in MCP?
   
   For those measures in the MCP Performance Measure Set for which CMS will be using MIPS benchmarks, please explore the latest benchmarks (performance thresholds) via the QPP website benchmark page. You can download a file to see the benchmark decile for each measure. Additionally, benchmark details will be published in the 2025 Payment and Attribution Methodologies paper.
    
5. Does the Total Per Capita Cost (TPCC) threshold requirement apply to Federally Qualified Health Centers (FQHCs)?
   
   Yes, the TPCC threshold for Performance Incentive Payment (PIP) eligibility (page 61 of the MCP Payment and Attribution Methodologies paper (PDF)) applies to both FQHCs and Standard participants. Beginning in 2026, all participants in Track 2 and Track 3 will need to meet or exceed the 30th percentile on TPCC performance, compared to the national TPCC benchmark. The national benchmark includes MCP participants and comparable non-participants.
   
   TPCC is calculated as an observed-to-expected (O/E) ratio. For each participant, observed costs are compared with expected costs, risk-adjusted for beneficiary comorbidities. An O/E ratio greater than 1 represents greater-than-expected per capita cost, and a ratio less than 1 represents less than-expected per capita cost. TPCC is an inverse measure; lower O/E ratios reflect better performance.
    
6. Are clinical quality benchmarks set and/or weighted locally, regionally, or nationally?
   
   Details on benchmark reference populations for each measure in the MCP Performance Measure Set are  available in Section 5.3.2 of the MCP Payment and Attribution Methodologies paper (PDF).
   
   Please note that the TPCC Threshold for PIP Eligibility (page 61 of the MCP Payment and Attribution Methodologies paper (PDF) is set against a national TPCC benchmark, whereas scoring for the individual TPCC measure as part of the PIP is set against a regional benchmark.
   
   All participants are held to the same benchmarks (performance thresholds) for the clinical quality measures as well as the cost and utilization measures used in the Performance Incentive Payment, regardless of the population they serve. To support participants serving higher need patients, MCP tiers the Enhanced Services Payment (ESP) by clinical and social risk, providing higher levels of predictable payments to participants that provide services to a higher share of high-needs beneficiaries. For more information on the ESP methodology, please see Section 3.0 of the MCP Payment and Attribution Methodologies paper.
    
7. Will performance metrics be assessed at the participant level or team-based level?
   
   For MCP, performance measures will be assessed at the participant (TIN) level. 
    
8. How will patient reported outcomes be incorporated into the model?
   
   The Depression Remission at 12 months is a patient-reported outcomes measure collected via the PHQ-9. Additionally, the Person-Centered Primary Care Measure (PCPCM) will assess patient experience. Both measures will be part of the performance incentive payment opportunity, which will reward organizations that perform well on these measures. 
    
9. Will the performance incentive payment (PIP) metrics be adjusted to reflect the complexity of providers’ patient populations?
   
   Some measures within the MCP performance measure set are risk-adjusted, according to the specifications of the measure steward. But we do not have additional adjustments that we will be making beyond that to inform the PIP. Please note the adjustments incorporated in the Enhanced Services Payments (ESPs).

Stakeholder Engagement & Learning

1. How does the CMS Innovation Center work with MCP stakeholders?
   
   The Innovation Center has worked closely with stakeholders across the health system in developing MCP. The model is designed to provide direct support to participating primary care practices and organizations to engage in practice transformation to provide high quality primary care. In its effort to reduce payer fragmentation, MCP will also be supporting value-based care in each MCP state through a state-based learning approach to support participants' success in the model.  We aim to engage primary care organizations, payers, state Medicaid agencies, and other stakeholders to catalyze broad system transformation.
    
2. Do you see MCP as building on previous learnings/knowledge of managed care (commercial organizations)?
   
   The structure of MCP differs substantially from managed care arrangements. MCP will provide prospective payment to primary care teams (at the organizational or TIN level) to support their provision of whole-person care to beneficiaries. We will also measure and reward quality and require organizations to meet care delivery requirements, including annual quality and performance measurement cycles and regular care delivery reporting to ensure organizations are providing a high standard of care.
    
3. Will there be a formal request for vendors to be able to provide technical assistance to participants? If so, when will it be released?
   
   CMS will formally solicit support through requests for proposals through the government procurement process.

Multi-Payer Alignment & Payment

1. As part of care management, can participants bill for remote physiologic monitoring (RPM) services under the model?
   
   Participants in Track 1 would continue to bill and be paid for remote physiologic monitoring on a fee-for-service basis. RPM services are not included in the list of care management services that are considered duplicative of the Enhanced Services Payment. For participants in Tracks 2 and 3, RPM services are paid prospectively as part of the Prospective Primary Care Payment. Participants in Track 2 receive a hybrid payment structure: 50% of primary care revenue is prospective via the PPCP and the other 50% is paid fee-for-service. For Track 2, participants will have this paid 100% prospectively through the PPCP, and will not be paid fee-for-service. You can find more information in our Payment and Attribution Methodologies paper (PDF).
    
2. Can model participants continue to bill for Chronic Care Management (CCM) monthly?
   
   MCP participants in all three tracks receive the Enhanced Services Payment for all attributed patients, which is a prospective, per-beneficiary-per-month payment designed to support enhanced care management and coordination. For Medicare FFS patients attributed to an MCP participant, the Enhanced Services Payment takes the place of CCM payment, so claims for these services will not be paid. Participants do not need to bill FFS for these claims. For unattributed patients in Medicare FFS, CCM will continue to be paid in accordance with the Medicare billing rules.
    
3. Should model participants still bill all claims to ensure future alignment and correct coding?
   
   Yes, participants should still submit claims for services that are being paid prospectively. Medicare Administrative Contractors (MACs) will zero-pay claims (not pay claims submitted) for services that are included in the Prospective Primary Care Payment (PPCP) for Track 3 or pay at half the rate for Track 2.
    
4. Do you believe these programs will cascade into the employer-based market?
   
   CMS is eager to discuss payer alignment in support of MCP with all payers to remove barriers to practice transformation, including employer-based payers. 
    
5. Will payments include beneficiaries enrolled in Medicare Advantage (MA) plans?
   
   No, the MCP payments described will not apply to Medicare Advantage beneficiaries. Only beneficiaries in Traditional Medicare, also known as Medicare fee-for-service, are eligible to be prospectively aligned to MCP. MCP is, however, a multi-payer model and invites MA programs to align with the model. Beneficiaries enrolled in Medicare Advantage may be included in a payer partner’s methodology by the specific carrier who provides their coverage, subject to the terms of that carrier.
    
6. Will this model focus on Medicare and Medicaid FFS care delivery, or is there also a managed care component?
   
   CMS plans to test MCP alignment with Medicaid in both FFS and managed care settings. States participating in the model are encouraged to work with managed care plans to align programs with MCP.
    
7. Could you expand upon the details/importance of data sharing across a variety of care settings/the care continuum
   
   MCP will require participants to meet several requirements around health IT adoption. MCP health IT requirements will be designed to meet model-specific standards to promote data and health information exchange (HIE), provide patients access to electronic health information, and avoid information blocking. MCP participants will benefit from the use of interoperable health IT systems and will see the value of data sharing, both between clinicians and suppliers and with patients. CMS will also share limited data on specialists that care for an MCP participant’s patients to support improved care coordination with specialists. 
    
8. Will you be providing state Medicaid programs additional funding to implement MCP?
   
   Payer participation is voluntary. No additional funding is being provided to Medicaid agencies that chose to partner with CMS  in MCP.
    
9. How will MCP payments compare to the combined revenue from fee-for-service (FFS) encounter rates? Chronic Care Management (CCM) reimbursement? Accountable Care Organization (ACO) shared savings?
   
   CMS will not estimate revenues across programs. Applicants should consider their billing patterns, patient population and other organizational characteristics when selecting a program or model for participation.
    
10. How would this program compare to current FQHC reimbursement mechanisms? Will the FQHC Prospective Payment System (PPS) go away for Federally Qualified Health Centers (FQHCs)?
    
    Each participant's MCP revenue will depend on their unique historical CCM billing patterns, the social and clinical risk of their attributed beneficiaries, and their performance on the quality, utilization, and cost measures. In MCP, FQHCs will continue to bill the Medicare FQHC PPS across all three tracks. In Track 1, FQHCs will bill the PPS on a fee-for-service basis. In Tracks 2 and 3, FQHCs will receive the Prospective Primary Care Payment (PPCP), which will be based on a list of primary care services from the Prospective Payment System. They will continue to bill the PPS at a reduced rate for these services and at the standard PPS rate for services not included in the PPCP.
     
11. How will the funding strategy support participants addressing health-related social needs (HRSNs) and the ability to collaborate with community partners?
    
    MCP participants will receive Enhanced Services Payments (ESPs) to support them in meeting care delivery requirements, including screening for social determinants of health (SDOH) and behavioral health integration requirements. Participants may use ESP revenue to collaborate with community partners in achieving these goals.
     
12. Will we be able to continue to bill for Chronic Care Management (CCM), Transitional Care Management (TCM), Medicare welcome and annual visits?
    
    Welcome to Medicare and Annual Wellness Visits should still be billed when provided to attributed Medicare beneficiaries. A list of CPT/HCPCS codes that will be used by CMS to calculate participants’ Prospective Primary Care Payments, which include Welcome to Medicare and annual wellness visits, are listed in Appendix G of the Request for Applications. A list of services considered duplicative of the Enhanced Services Payments is in Appendix F of the Request for Applications. MCP participants will not be paid for those services if billed for attributed Medicare beneficiaries. 
     
13. Does the upfront infrastructure payment (UIP) include technology infrastructure payments?
    
    Yes, UIP can be used to purchase or upgrade health IT as necessary for model participation. The allowable uses of the UIP are specified in the Request for Applications (PDF).
     
14. Is the upfront infrastructure payment (UIP) available per TIN (one payment per TIN) or will each clinic included in the TIN receive a UIP?
    
    The UIP is at the participant (TIN) level (one per eligible participant).
     
15. How is the area deprivation index (ADI) calculated? How does a beneficiary’s ADI score impact social risk tier assignment?
    
    ADI is a validated, area-level composite measure which is derived through a combination of 17 input variables from census data. National ADI is estimated annually through the US Census Bureau’s American Community Survey and reported publicly through the Neighborhood Atlas. ADI is a relative measure, typically reported by percentile (1-100) or decile (1-10), with a higher ADI value representing relatively greater socioeconomic deprivation. While ADI can be reported for an individual, it is important to remember that an “individual’s ADI” is the ADI of the census block group of their residence, and each individual faces a unique set and degree of social challenges. 
    
    ADI social risk tier assignment will be based on a regional reference population, such that ADI scores for attributed MCP beneficiaries are compared with the ADI scores for all Medicare FFS beneficiaries in the same region who meet MCP eligibility requirements. A beneficiary is assigned to an ADI tier based on where their ADI score falls within the regional distribution.
     
16. Will per-beneficiary-per-month (PBPM) payments be paid in addition to the Prospective Payment System (PPS) rates for visits?
    
    The Enhanced Service Payments as well as Performance Incentive Payments are paid in addition to reimbursement for primary care services. They are paid "on top" of current revenue.
     
17. How will the PPCP be partially reconciled with encounters with attributed Medicare beneficiaries?
    
    In MCP, there is potential for a small reconciliation to the PPCP to adjust for any changes in the proportion of primary care services that are provided outside of the MCP Participant TIN to their attributed beneficiaries. If the proportion of primary care provided outside of the MCP Participant TIN in the performance year exceeds the proportion provided in the previous year by a value of between $2-7 PBPM, CMS will make a downward adjustment of $2 PBPM to the participant’s PPCP. If the proportion in the performance year exceeds the proportion provided in the previous year by a value of more than $7 PBPM, CMS will make a maximum downward adjustment of $5 PBPM. No adjustment occurs if the outside-of-participant amount exceeds the year prior by less than $2 PBPM. 
     
18. If we begin in July of 2024, why do payments not begin until Jan 2025?
    
    In order to avoid overlap in payments between MCP and MSSP, no MCP payments will be made for participants dually in MSSP and MCP between July 1, 2024, and December 31, 2024. 7/1/24 and 12/31/24. Payments for MCP Participants not in MSSP will begin July 2024.

Care Delivery

1. Can care managers be utilized for individual practices if they are employed by a larger health system?
   
   MCP does not designate the arrangements through which organizations integrate care management and coordination into their care.  However, care management services must meet MCP eligibility requirements and be integrated and delivered as part of the primary care team.  Care managers should be able to build long-term relationships with the patients and providers.  In addition to team integration, care management staff must have appropriate access to the EHR/patient data for care delivery.
    
2. If we already have behavioral health integrated into our sites and we are charging for the visits, do we continue to bill for these services/visits for attributed patients?
   
   In Tracks 1 and 2, most behavioral health services would continue to be billed and paid on a fee-for-service basis. Once participants move into Track 3, certain behavioral health services are paid for prospectively via the Prospective Primary Care Payment (PPCP). This includes, for example, certain behavioral health screenings, care management for behavioral health, and cognition/functional assessments. You will still be required to file claims for these services, but payment will be fully prospective in Track 3. There are a few differences for FQHC participants. Please reference the Payment and Attribution Methodologies paper (PDF) for more detailed information.
    
3. What if a patient sees another provider in the same organization? How will that affect empanelment and data tracking if at all?
   
   Under MCP, beneficiaries will be attributed at the taxpayer identification number (TIN) level. Changes in a patient seeing different primary care clinicians within a TIN will therefore not impact a MCP participant's attribution. National Provider Identifiers (NPIs) provided in the Participant Roster will be used to ensure that the primary care services included in attribution were provided by eligible primary care clinicians.
    

4. Given the expectation to screen patients for health-related social needs (HRSNs), how will screening impact patient copays and other payments?

   In MCP, screening for HRSNs should not result in a copay for patients. In Medicare FFS, providers can now bill the new Social Determinants of Health (SDOH) Assessment code (G0136). The usual Part B deductible and coinsurance apply except when the SDOH risk assessment is furnished as an optional element of the AWV. The PFS distinguishes the SDOH risk assessment from an HRSN screening. The SDOH risk assessment is provided when a provider has reason to believe there are unmet SDOH needs that are interfering with the practitioner’s diagnosis and treatment of a condition or illness or will influence choice of treatment plan or plan of care. For more information, please reference the Health Equity Services in the 2024 Physician Fee Schedule Final Rule MLN (PDF). In MCP, the new SDOH Risk Assessment code (G0136), as well as the Community Health Integration (G0019, G0022), and Principal Illness Navigation (G0023, G0024, G0140, G0146) codes, are considered duplicative with the Enhanced Services Payment, and will therefore be denied reimbursement if billed. Therefore, the usual Part B deductible and coinsurance will not be applied.

Specialty

1. How does care integration work for multispecialty groups?

   If you already have specialists within your organization/TIN and at least one such specialist has a specialty type of cardiology, orthopedic surgery, or pulmonary disease, you may not need to find external Specialty Care Partners. Qualifying within-TIN specialists will be referred to as MCP Specialists for purposes of the MCP Model. More information can be found in the MEC (PDF) and ACM (PDF) Quick Reference Guides on the MCP web page.
    

2. Can an MCP clinician bill the MCP e-consult code, even if they don’t have a signed agreement with the specialist? Can you only consult with specialists that you have a partnership with?
   
   If you are a MCP Clinician, and in Track 2 or 3, you can bill the MCP e-Consult (MEC) code for a consultation with any specialist for a MCP beneficiary. The consult does not need to be with your Specialty Care Partner or MCP Specialist(s). More information can be found in the MEC (PDF) and ACM (PDF) Quick Reference Guides on the MCP web page.
    
3. Which tracks can bill the MEC and ACM codes?
   
   Model participants in Track 1 cannot bill the MEC or ACM. Starting in Track 2 and extending into Track 3, MCP Clinicians can bill the MEC code. Starting in Track 3, Specialty Care Partners and MCP Specialists can begin billing the ACM code once collaborative protocols are established. More information can be found in the MEC (PDF) and ACM (PDF) Quick Reference Guides on the MCP web page.
    
4. Are MEC and ACM codes available for FQHCs?
   
   Yes, MCP FQHC participants will be able to bill the MEC code in both Track 2 and Track 3, similar to Standard participants. Starting in Track 3, a MCP FQHC participant’s Specialty Care Partners may bill the Ambulatory Co-Management (ACM) code. More information can be found in the MEC (PDF) and ACM (PDF) Quick Reference Guides on the MCP web page.
    
5. How long does the e-consult have to be for to qualify for payment?
   
   The MCP e-Consult Code can be used by participants in Tracks 2 and 3 for e-consults. There is not a specific time requirement. More information can be found in the MEC (PDF) and ACM (PDF) Quick Reference Guides on the MCP web page.
    
6. What types of resources are used in team-based care models?
   
   The CMS Innovation Center will share more information and host an MCP webinar in the next month where we will provide additional model details, including the Care Delivery requirements. Additional technical guidance will also be provided through the Request for Applications later this summer. 
    
7. How do you see this model supporting non-physician providers who work with physicians to provide care in the primary care setting? How best should these providers integrate into this model?
   
   Through prospective payment and opportunities for additional revenue for primary care teams, the Innovation Center aims to encourage team-based care that includes non-physicians. CMS will set broad requirements – for example, requiring that teams work with a Community Health worker or someone who shares lived experience with their patients – but will not specify how care teams should be set up. 
    
8. How does the coordination of care between primary care practitioners and medical specialists fit in the progress you are achieving?
   
   Collaboration between primary care teams and specialists is key to achieving patient-centered care. MCP aims to improve communication between primary care organizations and specialists by requiring participants to establish relationships with Specialty Care Partners, who can receive additional revenue in exchange for meeting requirements set by the primary care organization.
    
9. How do you see pharmacies playing a role with PCPs and health systems in advancing value-based care?
   
   MCP will provide participating primary care organizations with additional revenue to better coordinate patient care across an inter-professional care team and incentivize improved patient outcomes. While CMS will not direct how a primary care organization incorporates pharmacists into their care team, previous models suggest that many primary care organizations have worked more closely with pharmacists to conduct medication management as part of their strategy to provide more comprehensive care.
    
10. What is the cost to the Medicare program for this new model?
    
    In 2010, Congress authorized CMS to test innovative health care payment and service delivery models that can improve patient quality and reduce the total cost of care in accordance with the requirements of section 1115A of the Social Security Act. This cost of operating this model will be supported using funding made available as part of this Act. The MCP model itself aims to lower overall Medicare spending by improving the value of care provided over the course of the model for impacted beneficiaries.
     
11. We are building team-based care at our organization. How can we reach these speakers to gain insight in connect with the CMS Innovation Center, payers and the state? 
    
    For questions about the Making Care Primary Model, please reach out to MCP@cms.hhs.gov; For information about your state's aligned program, please contact your state Medicaid Agency. 
     
12. How is CMS defining e-Consults?
    
    An e-consult is a form of interprofessional consultation where the specialist provides clinical guidance without seeing the patient face to face. e-Consults typically occur asynchronously, either integrated into the EMR or through a separate system. MCP requires participants to implement e-consults beginning in Track 2, which may require a separate e-consult technology solution to support coordinated, and clinically appropriate electronic exchanges between MCP participants and specialists. Starting in track 2, MCP participants will have access to a new MCP e-Consult (MEC) code designed to address barriers to utilizing current e-Consult and fee-for-service (FFS) Interprofessional Consult (IPC) codes.
     
13. For Track 3, how is the number of relationships with high-quality specialists determined?
    
    Starting in Track 2, MCP will require participants to sign a Collaborative Care Arrangement (CCA) and develop a coordinating relationship with at least one Specialty Care Partner, covering specialty types specified in the Request for Applications (PDF). This will also allow specialists at the Specialty Care Partner organization to furnish and be reimbursed for providing co-management with the MCP Participant on shared beneficiaries via the Ambulatory Co-Management (ACM) code in Track 3.
     

14. What is the financial incentive for the specialists to work with MCP participants?
    
    Starting in Track 3, Specialty Care Partners can furnish and be reimbursed for co-management on shared MCP beneficiaries with MCP participants via the Ambulatory Co-Management (ACM) code. MCP participants can also elect to share their Performance Incentive Payment (PIP) with Specialty Care Partners. 

     

15. What is the goal of establishing Collaborative Care Arrangements (CCAs) with specialists?
    
    The goal of the Collaborative Care Arrangement (CCA) in the Making Care Primary (MCP) Model is to increase and formalize collaboration protocols between primary care providers and specialists. The CCA policy does not intend to establish a preferred or obligated referral channel from a primary care organization to a certain specialty organization; instead, it seeks to promote greater specialty integration with primary care. The CCA, which is required beginning with Track 2, is an arrangement between a primary care organization and a specialty care organization that sets out expectations for communication, data sharing, care coordination, and general co-management of MCP-attributed beneficiaries for these two entities. Improving specialty communication and coordination is a specific transformational goal of the MCP Model, and, as such, participants will be required to use CCAs to ensure progress toward the desired outcome.

    Specifically, the CCA is a written arrangement between the MCP Participant (defined at the TIN-level) and the Specialty Care Partner (SCP) (also defined at the TIN-level) that governs the SCP’s responsibilities under the Arrangement. The CCA must address the following requirements:

    • Establish communication and data-sharing protocols for shared MCP-attributed beneficiaries;
    • Establish expectations for when a patient should be referred back to the primary care clinician (if necessary) and what should occur;
    • Establish parameters for coordinating care in order to improve quality of care and prevent unnecessary utilization; and
    • Establish general (not condition-specific) expectations for co-management of MCP-attributed beneficiaries between the SCPs who are billing the Ambulatory Co-management (ACM) Code, which will become available in Track 3, and the MCP Participant.

    For additional information on the specialty care integration strategy and its requirements, please see the MCP Participation Agreement.

     

16. Would an MCP CCA be in conflict with the Health Resources Service Administration’s (HRSA) requirements for referral arrangements for HRSA-supported health centers, a subset of FQHCs?

    No, HRSA’s requirements for HRSA-supported health centers (Health Center Program award recipients or look-alikes), a subset of FQHCs, do not prohibit health centers from participating in MCP or meeting the requirements of the specialty integration strategy for MCP, including establishment of CCAs with Specialty Care Partners (SCPs). Please review HRSA Technical Assistance Resources for Form 5A Column Descriptors and Service Descriptors for further Health Center Program guidance. In some cases, the CCA may be with a SCP (defined at the organizational/TIN-level) with whom the FQHC already has a Formal Written Referral Arrangement (Column III). Conversely, the CCA could serve to establish a new Formal Written Referral Arrangement (Column III). In other cases, the CCA could be with a SCP that meets the criteria for an informal referral arrangement and, as such, would not be listed on Form 5A: Services Provided. This will depend on how the FQHC structures the CCA, in collaboration with the specialist.

     

17. Can a Formal Written Referral Arrangement (Column III) for a health center serve as the MCP CCA or do I need to create a separate document?

    While a Formal Written Referral Arrangement for a health center may meet some or all of the collaboration goals of the MCP CCA, there is MCP-specific language that must be included in the CCA. This is detailed in Section 3.5: Collaborative Care Arrangements of the MCP Participation Agreement and includes language that must be included in the CCA around use of the MCP-specific Ambulatory Co-Management Code (ACM), any sharing of the Performance Incentive Payment, and requirements around program integrity notification.

    Acknowledging that it may be optimal for the Formal Written Referral Arrangement organization to also be the Specialty Care Partner (SCP), a participant could choose to amend their agreement to include these MCP-specific CCA requirements. They also could establish this CCA arrangement with the same specialty TIN in addition to the Formal Written Referral Arrangement or establish a CCA with a new specialty TIN.

     

18. What are the requirements for an MCP CCA?

    Each CCA shall comply with the criteria set forth in Section 3.5: Collaborative Care Arrangements of the MCP Participation Agreement. The terms detailed in the CCA should meet shared goals of the MCP Participant and Specialty Care Partner (SCP). Pursuant to Section 3.5.G of the MCP Participation Agreement, CMS has determined that the Federal anti-kickback statute safe harbor for CMS-sponsored model arrangements (42 C.F.R. § 1001.952(ii)(1)) is available to protect certain CCAs. CMS may audit the MCP Participant’s CCA(s) to ensure compliance with the terms set forth in the MCP Participation Agreement.

     

19. Does the CCA need to address care for all patients or just MCP-attributed Medicare fee-for-service (FFS) beneficiaries?

    At a minimum, the CCA must outline expectations for care collaboration for MCP-attributed Medicare FFS beneficiaries. However, participants may find that some aspects of a CCA may lend themselves to being implemented for all patients shared between the MCP Participant and the SCP, such as patient data sharing to facilitate co-management.

     

20. Is the MCP Participant restricted to using the Specialty Care Partners (SCP) for referrals of MCP beneficiaries?

    No, the CCA does not establish a required referral relationship with the SCP.

     

21. Does HRSA need to review the CCAs as part of site visits or compliance checks?

    No, the CCAs are separate and distinct from any HRSA requirements. If a health center wishes to make changes to the services within its HRSA Health Center Program scope of project, it must follow HRSA’s guidance to request such changes.

22. Are payments made as part of the CCA?

    If the MCP FQHC Participant participates in Track 2 or Track 3, it may bill CMS for a unique MCP e-Consult (MEC) code. The MEC code can be billed for a consultation with any specialist, and it does not require that the specialist consulting is from a TIN listed on a Specialty Care Partner (SCP) List. Billing of the MEC is not connected to the MCP CCA policies. For more information, please read the Quick Reference Guide: Making Care Primary e-Consult (MEC) Code (PDF).

    For FQHCs, the MCP FQHC Participant’s SCP may bill CMS for a unique Ambulatory Co-Management (ACM) code.  The ACM code is available only to SCPs, specifically those with active CCAs with an MCP Participant in Track 3. The MCP FQHC Participant’s SCP is eligible to bill the ACM if the MCP FQHC Participant is in Track 3; and its SCP that bills CMS for the ACM code is identified on the MCP FQHC Participant’s SCP List. For more information, please read the Quick Reference Guide: Ambulatory Co-Management (ACM) Code (PDF).

     

23. Can an FQHC have a Specialty Care Partnership with itself?

    No, FQHCs cannot have their TIN function as their SCP even if there are specialists within their TIN. For this reason, specialists within an FQHC MCP Participant TIN cannot bill the ACM code.

     

24. Where can I access my organization's list of MCP-attributed beneficiaries and a quarterly payment report?

    MCP Participants will be able to access a quarterly list of attributed beneficiaries and a detailed MCP payment report in the MCP Custom Export Tool in the MCP Expanded Data Feedback Reporting application within the CMS Enterprise Portal. Quarterly payment and attribution reports will be made available to Participants around the time MCP Model payments are made each quarter.

     

25. When will I know if my organization is eligible for the Upfront Infrastructure Payment (UIP)?

    Track 1 Participants who were accepted into the model with at least 125 MCP-attributed beneficiaries and who are not concurrently enrolled in the Medicare Shared Savings Program (MSSP) in 2024 will be notified of their final UIP eligibility by August 2024. Those deemed eligible will be required to submit an initial spend plan in the MCP Participant Portal in order to receive the first lump sum UIP.

    Track 1 participants who were accepted into the model with fewer than 125 MCP-attributed people or are concurrently enrolled in MSSP in 2024 will receive their final UIP eligibility determination by December 31, 2024.

    Participants accepted into the model with fewer than 125 MCP-attributed people will be required to achieve at least 125 cumulative unique MCP-attributed beneficiaries by November 1, 2024, in order to be considered eligible for the UIP. Participants concurrently enrolled in both MCP and MSSP in 2024 will be required to withdraw from MSSP prior to Performance Year 2025 to be considered for the UIP. Please refer to Section 8.2 of the Amended and Restated MCP Participation Agreement for more information.

     

26. My organization is enrolled in both the MSSP and MCP for 2024. How and when do we notify CMS of our decision to stay in one model or the other for 2025?

    Organizations enrolled in both MSSP and MCP for Performance Year 2024 will not receive MCP Model payments in 2024. Organizations must withdraw from MSSP ahead of Performance Year 2025 to be eligible to remain in MCP and begin receiving model payments in 2025. By September 5, 2024, MSSP ACOs must remove organizations that wish to withdraw from MSSP from their ACO participant list for Performance Year 2025. Organizations that remain on the MSSP ACO participant list for Performance Year 2025 will no longer be eligible to participate in MCP.

    Organizations that choose to remain in MSSP for 2025 must notify the MCP model team in writing of their withdrawal from MCP by November 30, 2024.

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