Medicaid Advanced Primary Care Program

Requirements​

Care Transformation Requirements (CTRs)

Access and Continuity

• Use Managed Care Organization (MCO) assignment of a Medicaid member to a PCP to empanel Medicaid participants to a provider. 

• Ensure Medicaid members have regular access to the care team or provider through at least one alternative care strategy (e.g., same or next-day appointments, telehealth, patient portal, after hours or weekend visit). 

• Outreach to assigned Medicaid members who have not been seen by primary care, with the goal of getting them in for a visit and maintaining regular contact. 

Care Management

• Ensure Medicaid members who have received follow-up after ED, hospital discharge, or other triggering event receive short-term (episodic) care management.

• Ensure Medicaid members receive a follow-up interaction from the practice within one week for ED discharges and two business days for hospital discharges (expect a 50% threshold for hospital & ED followup rates).

Comprehensiveness and Coordination

• Specialist referral management - use a process to refer patients to necessary appointments with specialists.

• Behavioral health screening and referral - use measurement-based care for behavioral health for Medicaid members, leveraging standardized screening tools. Refer members as necessary to the behavioral health Administrative Services Organization (ASO), Carelon, for care coordination. 

• Screen Medicaid members for social support services needs using a standardized screening tool. Facilitate access to resources that are available in the practice’s community for Medicaid members with identified needs. 

Pediatrics Requirements

• Newborns should have an evaluation within 3 to 5 days of birth and within 48 to 72 hours after discharge from the hospital to include evaluation for feeding and jaundice (AAP). 

• Providers should administer a brief standardized, validated tool to aid the identification of children at risk of a developmental disorder to address the following areas, as ageappropriate: 1) speech and language development 2) gross and fine motor development, 3) self-help and self-care skills, 4) social development, 5) cognitive development, and 6) presence of learning disabilities. At the 18 and 24-month well-child visit, it is also required to administer a structured autism specific screening. For recommended screening tools and more information, please refer to the Maryland HealthyKids manual. 

• In a timely manner, providers should complete forms needed for participation in school, early childcare, and sports as appropriate. These may include the Maryland Department of Education Health Inventory form, Medication Administration Authorization form, or the Immunization Certification form. These forms may be provided by the parent/legal guardian, but can also be downloaded from the Maryland Department of Education website. 

CRISP

• Submit or update a CRISP Event Notification Delivery (CEND) panel every 90 days. 

• Download the practice organization's MCO Assignment List from the CRISP ‘AllPayer Population’ tile on a quarterly basis to understand Medicaid member assignment. 

• View the Prediction Tools reports in the MultiPayer Reports platform within CRISP at least every 30 days. 

• Use the Multi-Payer Reports Platform in CRISP at least quarterly to monitor data for quality improvement over time. 

Performance Measures

​The 2027 Quality Incentive will include four Pay-for-Performance measures calculated from Medicaid claims and encounters and four electronic Clinical Quality Measures (eCQMs) as Pay-for-Reporting measures that participants will submit to CRISP.

Pay for Reporting Measures

• Screening for Depression and Follow-Up Plan (CDF-CF and AD): Ages 12 to 64.

• Comprehensive Diabetes Care: Hemoglobin A1c Poor Control (>9.0%) (CDC-HbA1c Poor Control).

• Controlling High Blood Pressure (CBP).

• Colorectal Cancer Screening (COL).

Pay for Performance Measures

• Emergency Department Utilization (EDU).

• Acute Hospital Utilization (AHU).

• Child and Adolescent Well-Care Visits (WCV).

• Developmental Screening in the First Three Years of Life (DEV-CH).