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Center for Medicare and Medicaid Innovation Primary Care Models
Learn about the four latest payment models putting your specialty at the center of a strategy to ensure that all Americans have access to high-quality, affordable, and person-centered care.
What is the Center for Medicare and Medicaid Innovation?
CMMI is a part of the Centers for Medicare & Medicaid Services (CMS) within the U.S. Department of Health and Human Services. CMMI was created by the Affordable Care Act (ACA) in 2010 to test new payment and service delivery models that could improve care quality and efficiency for Medicare, Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries. Elevating primary care is central to the Innovation Center’s strategy.
Jump to a Section: ACO Primary Care Flex Model | Making Care Primary | Primary Care First | ACO REACH | Past Models
ACO Primary Care Flex Model
ACO PC Flex was announced in March 2024 and is designed to implement prospective primary care payment into the Medicare Shared Savings Program (MSSP). The ACO PC Flex will launch January 1, 2025. ACO PC Flex aims to:
- Expand access to high-quality, accountable care and improve the patient experience for people with Medicare.
- Enhance primary care payment and spur innovative approaches to care delivery, such as team-based care that is proactive, person-centered and drives quality improvement.
- Narrow disparities in health care outcomes.
- Reduce program expenditures while preserving or enhancing the quality of care for people in the Shared Savings Program.
- Strengthen participation incentives for new and low revenue ACOs in the Shared Savings Program.
Payment Design
ACO PC Flex includes two main payment components:
- A one-time $250,000 Advanced Shared Savings Payment to all participating ACOs.
- A monthly prospective primary care payment (PPCP) to ACOs and their participating primary care providers, including Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), to address the medical and health-related social needs of their patients.
Eligibility Criteria
- ACO PC Flex will be available to up to 130 new or renewing low-revenue ACOs that complete their SSP application by June 17, 2024.
- ACOs will also be required to complete the ACO PC Flex application in addition to the SSP application.
- ACOs may not participate in PC Flex and receive the SSP Advance Investment Payments (AIP).
- Primary care physicians and other clinicians not affiliated with a participating ACO are ineligible to participate.
ACO Primary Care Flex Resources
CMS:
- ACO Primary Care Flex Model Webpage
- ACO PC Flex Model Press Release
- Webinar: ACO PC Flex Model - Overview (April 4, 2024)
- Shared Savings Program
- Shared Savings Program Applications
Announced in June 2023, the Making Care Primary (MCP) model includes three tracks that each focus on goals aimed at creating pathways to enter value-based payment. The application period is closed.
Making Care Primary aims to:
- Ensure patients have access to and receive primary care that is integrated, coordinated, person-centered and accountable.
- Create a pathway for primary care organizations and practices – especially small, independent, rural, and safety net organizations – to enter value-based arrangements.
- Improve quality of care and health outcomes for patients while reducing program expenditures.
Eligibility Criteria
The model will be tested in eight states based on agreements with state Medicaid agencies regarding alignment around program principles and model dimensions that matter to family physicians. The eight states are Colorado, Massachusetts, Minnesota, New Jersey, New Mexico, New York, North Carolina and Washington.
Organizations ineligible to participate include rural health clinics, concierge practices, current Primary Care First (PCF) practices, current Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model participants, and grandfathered tribal federally qualified health centers (FQHCs). Concurrent participation in MCP and the Medicare Shared Savings Program (MSSP) will not be allowed after the first six months of the model.
Program Tracks
The model includes three tracks that each focus on specific goals. The AAFP has created profiles and a calculator to help you understand the tracks and potential revenue gains.
Track 1. Building Infrastructure
Participants work to establish a foundation for implementing advanced primary care services such as patient risk stratification, data review, workflow development, chronic disease management, and social determinants of health (SDOHs) screening and referral. Payment for primary care will remain fee-for-service (FFS)-based while CMS provides financial support to help participants develop care transformation infrastructure and build advanced care delivery capabilities. Participants begin earning financial rewards for improving patient health outcomes.
Track 2. Implementing Advanced Primary Care
Participants build on Track 1 requirements by partnering with social service professionals and specialists, implementing care management services and screening for behavioral health conditions. Payment for primary care will shift to a 50/50 blend of prospective, population-based payments and FFS payments. CMS will continue some financial support for building advanced care delivery capabilities, even as participants are able to earn increased financial rewards for improving outcomes.
Track 3. Optimizing Care and Partnerships
Participants begin using quality improvement frameworks to optimize and improve workflows, address silos to improve care integration, develop social services and specialty care partnerships, and deepen connections to community resources. Payment for primary care will shift to fully prospective, population-based payment while CMS continues minimal financial support to sustain care delivery activities. Participants can earn even greater financial rewards for improving patient health outcomes.
Have More Questions About MCP?
Watch a recorded webinar about the program, hosted by CMS, the AAFP and the ACP.
Resources
AAFP:
- Policymakers Heed AAFP’s Call to Bolster Primary Care Practices and Improve Competition | Press Release
- Primary Care-focused APM Checks AAFP Advocacy Boxes | AAFP News
- Washington Hears Us on Consolidation and Physician Payment | A Word From the President
- Here’s What I Just Told Senators About Health Care Consolidation | In the Trenches
CMS:
Primary Care First
Primary Care First (PCF) aims to provide increased flexibility to primary care physicians to support innovative care delivery approaches based on patient population needs and preferences. It is a voluntary five-year, multipayer model being tested in 26 regions. Applications to participate are currently closed.
About PCF
PCF alters the payment structure for primary care clinicians from traditional fee-for-service (FFS) to prospective payments with a potential bonus. Practices in model receive payments for primary care services through three mechanisms:
- The total primary care payment (TPCP), which is made up of a risk-adjusted population-based payment (ranging from $28 to $175 per-beneficiary per-month [PBPM] based on average panel risk) and a flat visit fee (~$40) for each face-to-face primary care visit.
- A performance-based adjustment paid quarterly, based on five quality measures and performance on acute hospital utilization. The performance-based adjustment applies to total primary care revenue and ranges from -10% to a bonus of up to 50%.
- Standard FFS for services provided outside those covered by the flat visit fee, such as procedures and vaccines.
Resources
AAFP:
- AAFP Primary Care First Dashboard – CPC+ Practices | Excel spreadsheet
- AAFP Primary Care First Dashboard – Non-CPC+ Practices | Excel spreadsheet
- AAFP Practice Assessment Checklist | PDF download
- Primary Care First Model Question & Answer Session with CMMI Staff | PDF download | Member login required
- Primary Care First Model: Interactive Office Hours With CMS | Recorded webinar
CMS:
About ACO REACH
The ACO Realizing Equity, Access, and Community Health (ACO REACH) Model has three key aims:
- Advance health equity to bring the benefits of accountable care to underserved communities
- Promote provider leadership and governance
- Protect beneficiaries and the model with more participant vetting, monitoring, and greater transparency
ACO REACH (previously call the Global and Professional Direct Contracting Model) is a five-year voluntary model that began in April 2021 and includes two voluntary risk-sharing options. In each option, participating providers accept Medicare claims reductions and receive at least some of their compensation from their ACO.
The two participation options are:
- Professional – Includes monthly risk-adjusted primary care capitation payment for enhanced primary care services and 50% shared savings/losses.
- Global - Includes monthly risk-adjusted primary care capitation payment for enhanced primary care services OR a monthly risk-adjusted total care capitation payment for all services provided by the direct contracting (DC) entity and preferred providers with whom the DC entity has an agreement and 100% savings/losses.
Resources
Never tried value-based payment? Want to know why you should? Members share their experiences.
CPC+ provides access to increased and up-front payment for primary care. CPC+ has three components that de-emphasize fee-for-service and increase payment to support practice improvement and capacity building. Both CPC+ tracks offer three payment components:
- Care management fee (CMF): Practices will receive a per-beneficiary-per-month (PBPM) CMF for their Medicare Part B patients. The fee will be paid prospectively on a quarterly basis and will be based on the complexity of the patient population. The average PBPM CMF will be $15 for Track 1 and $28 for Track 2. Track 2 practices will receive a $100 PBPM CMF for the most complex cases, such as patients with dementia.
- Performance-based incentive payment (PBIP): All CPC+ practices receive their PBIP as a prospective payment at the beginning of each program year in order to meet patient needs and build capacity. At the end of the program year, practices that do not meet quality and cost benchmarks will repay some or all of this payment. The PBIP will be equivalent to $2.50 PBPM for Track 1 and $4 PBPM for Track 2.
- Payment under Medicare physician fee schedule: All CPC+ practices will continue to bill and receive fee-for-service (FFS) payments. Track 1 practices will continue to receive standard FFS payments. Track 2 practices will receive a hybrid payment with a prospective portion paid quarterly -- the Comprehensive Primary Care Payment (CPCP) -- coupled with reduced fee-for-service payments. The CPCP plus FFS payments together will be larger than the practice's historical FFS payment.
CPC+ practices receive technical assistance and support through national and regional learning contractors and are able to connect with and learn from other CPC+ practices through an online platform.
Within the Quality Payment Program (QPP), CPC+ has been designated as an Advanced Alternative Payment model (AAPM). For the 2017 performance period, an AAPM entity must do one of the following for all of its eligible clinicians to be qualifying participants (QPs):
- Receive at least 25% of its MEdicare Part B payments through AAPM, or
- See at least 20% of its Medicare patients through the AAPM
QPs will receive an annual 5% lump sum bonus. The bonus applies in payment years 2019-2024.
QPs will be excluded from the MIPS reporting requirements.
QPs will receive a 0.75% increase to their Medicare physician fee schedule (PFS) beginning in 2026.
AAPM entities that do not meet either the payment threshold or the patient threshold can opt to participate in MIPS and will be scored using the APM Scoring Standard.
For Round 1, practices of any size that meet the QP threshold are eligible for the lump sum bonus. For Round 2, practices whose TIN has 50 of fewer clinicians and meets the QP threshold are eligible for the lump sum bonus.