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New Population-Based Option for the Maryland Primary Care Program in 2023

The Centers for Medicare and Medicaid Services (“CMS”) recently announced that it is accepting applications for participation in a new population-based track (“Track 3”) as part of the Maryland Total Cost of Care Model’s Maryland Primary Care Program (“MDPCP”), which will begin on January 1, 2023 and continue through December 31, 2026. Track 3 provides a new option for participants to provide high value primary care services to Medicare beneficiaries within the State of Maryland.

Background

The MDPCP is part of the CMS Innovation model that aims to produce at least $1B in Medicare savings in the State of Maryland by the end of 2023. The MDPCP offers multiple “tracks” for participation under which primary care providers offer advanced primary care services including care management to their patients. While Tracks 1 and 2 of the MDPCP incentivize providers to reduce potentially avoidable hospital admissions and unnecessary costs while improving quality of care for their attributed Medicare beneficiaries, Track 3 increases the total cost of care accountability of participating practices by introducing upside and downside risk based upon performance of certain quality, utilization and efficiency metrics.

Eligibility

Primary care providers who provide services to Medicare beneficiaries within the State of Maryland and meet certain criteria are eligible to apply for the Track 3 program. In addition, Care Transformation Organizations (“CTOs”) that utilize an interdisciplinary care management team to offer care coordination, pharmacist services, health and nutritional counseling, behavioral health support, and social services are eligible to apply for the Track 3 program. Primary care practices are permitted, but not required, to partner with eligible CTOs, which may include accountable care organizations, hospitals, managed service organizations, clinically integrated networks, or other support organizations. In contrast, CTOs are required to partner with primary care practices for the MDPCP program. For 2023, federally qualified health centers are not eligible to apply for the Track 3 program although they may participate in Tracks 1 or 2 of the MDPCP.

Payment Methodology

Track 3 of the MDCPC provides alternative payments in the form of incentives or penalties to participants for the provision of enhanced care management services and performance. Participants in the Track 3 program are eligible for a prospective service fee and a flat visit fee paid at the time of service for certain primary care services. In addition, participants are eligible for payment relating to the identification of health-related social needs for high-cost and disadvantaged Medicare beneficiaries and the improvement of health outcomes. Unlike payments in Tracks 1 or 2, Track 3 payments are subject to an upwards (up to 25%) or downwards (up to -10%) adjustment based on performance of certain quality, utilization and efficiency metrics.

Timing

Applications for the MDPCP, including Track 3, are required to be submitted on or before July 15, 2022 at 11:59 PM ET. Prior to submission, interested participants should review the requirements of the MDPCP to determine eligibility, calculate potential payments based on the designated program tracks, and assess potential partnership opportunities, as applicable. CMS has noted that it will not accept submissions for 2023 after the deadline and that it expects to publish a request for applications for performance year 2024 in Spring 2023.

Copyright © 2023, Sheppard Mullin Richter & Hampton LLP.National Law Review, Volume XII, Number 189
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About this Author

Special Counsela

Amy Dilcher is special counsel in the Corporate Practice Group in Sheppard Mullin's Washington D.C. office.

Amy’s practice focuses on transactional and regulatory matters, helping healthcare organizations achieve their strategic business initiatives while navigating complex regulatory issues and mitigating risks associated with healthcare regulations in the areas of strategic affiliations, mergers and acquisitions, hospital and physician transactions, managed care matters, and other contractual arrangements. She also advises on a wide range of...

202-747-1875
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