General Questions:
What is the implementation timeline?
A voluntary letter of intent is open as of September 1, 2022 and is due to DHCS by October 14, 2022. The required application is expected in December and will be due in January 2023. Health centers will be selected by March 2023. Expected implementation start date is January 1, 2024.

Which health centers can participate in this initiative?
All FQHCs will have the opportunity to apply for the APM. All affected sites under each PPS must participate conjointly (e.g. all intermittent, mobile sites attached to parent license, etc.).

Will we be required to participate in the APM?
The APM is voluntary.  FQHCs can drop out with 180 days notice prior to the start of the contract year; for FQHCs going live in 2024, the deadline to withdraw is August 1, 2023.

Which patient population(s) are included in the APM?
The APM Per Member Per Month (PMPM) rate is based upon Medi-Cal Managed Care members. Any patients not in Managed Care are excluded from the APM PMPM rate and will continue to be paid as they are currently paid today.

It's important to note that as new populations are added to Medi-Cal Managed Care, and they are assigned to FQHC APM clinics, the clinic will receive a PMPM for them. For example, the undocumented adults who are entering Managed Care in 2024 - to the extent they are assigned to APM clinics, they will result in a PMPM to the clinic.

I would like to understand why we would want to do APM?
There are a lot of reasons FQHCs are interested in the APM. First and foremost, the design of the APM is to relax some of the constraints of PPS (e.g. billable providers, four walls) while ensuring the resources (e.g., the revenue to health centers on a per member basis) will remain the same or better.  Many FQHCs anticipate that this additional flexibility will allow them to deliver more patient-centered, whole-person care (e.g., integrated PC/BH care and connection to social services, 2 visits on the same day, engagement with CHWs, etc.), resulting in better access, improved outcomes and more satisfaction for care team members working at the top of their licenses.

Some health centers foresee internal cost savings as health centers use non-provider team members to deliver care-- even after some of these internal cost savings are reallocated to non-traditional care (e.g., virtual care, group visits, RN visits, CHW outreach/health promotion, etc.). Additionally, cash flow up front is a huge opportunity compared to waiting for reconciliation payments for years.

Also, all plan P4P and care management/coordination (ex. Health Homes, WPC, ECM) payments would remain in place -- over and above APM payments just as they are over and above PPS today. The hope is that with additional flexibility to deliver care, there will also be a chance for the clinic to perform better on health plan P4P measures.  

Application Questions:
When is the application due?
The voluntary and non-binding letter of intent is open as of September 1, 2022 and is due to DHCS by October 14, 2022. If a health center is at all interested in the APM for the initial year of 2024, CPCA highly encourages them to submit an LOI. This information will provide DHCS, Managed Care Plans, and health center associations valuable information on where there is interest so we can focus our preparedness efforts and resources.

The required application is expected in December and will be due in January 2023. LOIs and Applications should be sent to FQHC APM Email inbox at FQHCAPM@dhcs.ca.gov.

Applications for participation in future years of the APM will be released on a rolling, year-over-year basis.

The LOI allows for a health center to add information about three health center sites on questions 1 and 2, PPS rates/sites and lives, respectively. How does an organization with more than 3 sites interested share information on questions 1 and 2?
Any additional sites can be added on as an appendix. Applicants must provide complete information for each additional site.

How should health centers handle the Health Plan assessment form for new plans coming into their county?
DHCS is still determining how to address new health plans and changes to county models. They will share information as soon as it is available.

Operational Questions:
What if a CHC has fewer visits in the APM?
The expectation is that traditional PPS visits will go down in the APM structure as some traditionally billable PPS visits are substituted for with other forms of care (see response to Question: What are alternative engagement services?). CHCs will have been paid a PMPM rate based on historical utilization and will keep this full amount of money as long as they achieve quality metrics. The state under APM federal rules is required to pay CHCs "at least what a CHC would have received under PPS" under an APM. In both Oregon and Washington, health centers under similar APMs have 1) transformed care, resulting in fewer traditional PPS visits and 2) not suffered any financial penalties even after tying a small portion of the PMPM to quality.

What are alternative engagement services?
Alternative engagement services are defined as services that are not billable under PPS but that meet member needs (e.g., community health worker visits, nurse visits at a patient's home, group visits, clinical pharmacist visits, same day visits (e.g. behavioral health and physical health visit, phone visits). As the APM is implemented, it is expected that FQHCs will see a decrease in PPS-eligible encounters due to practice transformation and an increase in "alternative touches". The full list of Alternative Engagement codes can be found here.

In the APM, will we still have to bill claims daily?
APM Health centers will not bill claims to MCPs or DHCS; although, they should track PPS-eligible visit counts for reporting purposes. APM Health centers will be expected to submit complete and accurate encounter data to their MCP (or delegate) for services rendered.

For any Medi-Cal beneficiaries or visits that are excluded from the APM, you would continue to bill claims and T1015 or T1015SE or as you do today (ex. dental visits, specialty mental health visits, duals visits, any non-Medi-Cal-managed care patients such as pregnancy only or FFS.

Quality Questions:
What access and quality reporting is required?
APM FQHCs on an annual basis must meet the following access and quality threshold measures. 
Access Measures: FQHC must maintain a floor of 70% of historical PPS visits (sum of PPS visits and alternative care services) to maintain participation in the APM)
Quality Measures: FQHCs must achieve minimum performance requirements that increase year over year. See Participation Linked to Quality and Access on slide 16.

Corrective Action Plans (CAP) may be triggered if these thresholds are not met. If there is no improvement in performance after the CAP, the State may implement financial sanctions up to 5% of the allowable amount excess revenues (e.g., wedge) at risk.

In order to retain APM PMPM reimbursement exceeding the PPS rate (aka Pay for Transformation or "wedge" amount), the FQHC must meet quality targets established by DHCS. FQHCs must report on a total of 12 measures, at least two measures from each of six domains. 10 measures are held at very small risk. Risk-based payment does not start until Year 2 of the APM. See Payment Linked to Quality (Ladder) on slide 17.

Can an FQHC change the chosen measurements from year to year?
Some quality measures are required reporting if the health center has sufficient patients in the denominator for that measure. FQHCs may change the optional measures they report from year to year. Reported measures will be held to the minimum performance requirement for that year.

Will quality measures include all patients or just patients under PMPM?
Quality measures will be reported/measured in aggregate (meaning totals of all contracted Plan beneficiaries) by site for attributed Medi-Cal Managed Care patients.

Where can I find the quality measure set?
The measure set is here.

Finance Questions:
How is the APM PMPM rate calculated?
A site will have one APM PMPM rate per site per Managed Care Plan. E.g. An organization in a two-plan county goes into APM with three sites. That organization would have six APM PMPM rates.

The APM PMPM rate is calculated using the following equation:
Historic Utilization (SFY 21-22 encounters, including walk-in utilization by MCO members) x  PPS
MCO members assigned (member months) to the FQHC in SFY 21-22

For health centers going live in 2024, the historic utilization base year is SFY 2021-2022 (July 1, 2021 to June 30, 2022). For FQHCs joining the APM after 2024, the state will utilize the number of encounters based on a utilization base "year" determined by the State on the most recent complete and appropriate utilization available. Unassigned health plan member walk-ins will be included in the historic utilization.

What annual reconciliation is there in an APM?
Congress only authorized Medicaid to pay FQHCs using an APM so long as the APM payment results in payment to the center or clinic of an amount which is at least equal to the amounts otherwise required to be paid to the center or clinic" under PPS. The FQHC is guaranteed at least PPS on a per encounter basis.

DHCS will review and annually reconcile the total payments made to each FQHC that participates in the APM PMPM to ensure the APM PMPM payment made by the MCO is what the FQHC would have received under PPS. FQHC attestation of receipt of PPS is not sufficient, the FQHC must be able to document receipt of at least PPS.

If an APM clinics' actual utilization is more than the historic utilization that the rate was set at, DHCS will pay the FQHC the difference if/when payments are less than the total amount the FQHC would have received under PPS. There are no PPS over payments so traditional reconciliation paybacks from FQHC to PPS is not expected. Clinics may have to pay the state if access and quality gate/ladder is not met.

What happens if we often see patients who are not assigned to us? 
The historic utilization which the PMPM rate is based on includes visits from contracted Plan members:
assigned to the health center and assigned to the site
assigned to the health center but not assigned to the site
not assigned to the health center, but seen at the health center

FQHCs in the APM would be paid PPS for visits from non-contracted Medi-Cal Managed Care Plan enrollees even if they are not assigned to that provider/site/organization. For Medi-Cal managed care patients who you see who are not assigned to you, DHCS has proposed  the FQHC would receive a straight PPS payment from the plan (or IPA) rather than billing a code 18 & awaiting reconciliation with the state.

How are Pay for Performance dollars and payment for non-PPS services (e.g. ECM, CS, etc.) payments protected?
All plan P4P and supplemental payments for Enhanced Care Management and Community Supports remain in place -- over and above APM payments just as they are over and above PPS today. The hope is that with additional flexibility to deliver care, there will also be a chance for the clinic to perform better on health plan P4P measures.  

Prospective Change in Scope Questions:
Coming soon.