Making Care Primary (MCP) Model Frequently Asked Questions
- Eligibility & Participation
- Stakeholder Engagement & Learning
- Multi-Payer Alignment & Payment
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
3). 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.
4). When will the model be an option for states who aren’t one of the eight original participants?
MCP will operate in eight states. At this time, we are not planning to expand to additional states, but CMS will continue to evaluate the model and may reassess based on initial program experience.
5). 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.
6). 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. 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.
7). 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
8). 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.
9). 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.
10). 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, Section 2A- Application and Applicant Eligibility Criteria. This list of programs does not include Medicaid value-based purchasing programs.
11). 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.
12). 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.
13). 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.
14). 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.
15). 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
16). 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.
17). 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.
18). 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
19). 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.
20). 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.
21). 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.
22). 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.
23). 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.
24). 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.
25). 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.
26). 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.
27). Will applicants receive feedback during the application process such as estimated per-beneficiary-per-month (PBPM) amount?
Applicants will receive estimated Enhanced Service Payments PBPM and Prospective Primary Care Payment PBPM amounts after they are selected to participate in MCP, and prior to signing the Participation Agreement.
28). How can a practice estimate what their Prospective Primary Care Payment (PPCP) rate will be under MCP?
CMS will provide information on a prospective participant’s attributed population prior to the start of the model. The PPCP is meant to keep primary care revenue consistent with expected primary care revenue for a given participant.
29). 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.
30). 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.
31). 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).
32). 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.
33). 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.
34). 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.
35). If we begin in July of 2024, why do payments not begin until Jan 2025?
Payments for MCP participants not in the Medicare Shared Savings Program (MSSP) will begin July 2024. For participants dually in MSSP and MCP between 7/1/24 and 12/31/24, no MCP payments will be made to avoid overlap in payments between MCP and MSSP.
36). 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.
37). 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.
38). 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.
39). 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.
40). 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.
41). 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.
42). 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.
43). 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. 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.
44). 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.
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