Overview of Upcoming Changes to Provider Accountabilities and Population Health Model in 2025
Our Provider Resources Center is the go-to for key dates, annual and Population Health Model quality measures, targets, and percentiles, payment structures, compliance tips, and more.
Below get a sneak peek at the upcoming 2025 updates to:
- Population Health Model measure descriptions, targets, and percentiles
- Self-reporting dates and deadlines
- Payment structures
- Provider accountabilities
- Regional Clinical Representatives
Updates for 2025: Population Health Model Measures
Here find upcoming new targets and percentile benchmarks for Population Health Model measures for 2025.
| 2025 Population Health Model Measure | Measure Description | 2025 Target Rate | Percentile Benchmark |
|---|---|---|---|
| Child and Adolescent Well-Care Visits 3-21 (HEDIS WCV) | The percentage of members 3-21 years of age who had at least one comprehensive well care visit with a PCP or an OB/GYN practitioner during the measurement year. | 64.74 % | Medicaid 90th (3-21) |
| Developmental Screening in the First Three Years of Life (CMS Child Core C-DEV) | The percentage of children screened for risk of developmental, behavioral, and social delays using a standardized screening tool in the 12 months preceding, or on their first, second, or third birthday. | 51.60% | Medicaid Child Core Set 75th |
| Medicare Annual Wellness Visit | A yearly check-up for Medicare enrollees assisting participants the opportunity to gain information about their patients, including medical and family history, health risks, and specific vitals. A proactive approach to encourage patients to be proactive about their health and engage in preventive health services. | 51.80% | National ALL ACO Benchmarking - 50th |
| Hypertension: Controlling High Blood Pressure (Quality ID# 236, HEDIS CBP) | The percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure (BP) was adequately controlled (<140/90 mmHg) during the measurement. | 69.37 % | Medicaid 75th |
| Initiation of Substance Use Disorder Treatment (HEDIS IET) | The percentage of new substance use disorder (SUD) episodes that result in treatment initiation and engagement. Two rates are reported: Initiation of SUD treatment (within 14 days) and Engagement of SUD treatment (within 34 days of initiation). | 44.51% | Medicaid 50th |
| Engagement of Substance Use Disorder Treatment (HEDIS IET) | The percentage of new substance use disorder (SUD) episodes that result in treatment initiation and engagement. Two rates are reported: Initiation of SUD treatment (within 14 days) and Engagement of SUD treatment (within 34 days of initiation). | 19.01% | Medicaid 75th |
| Follow Up after ED Visits for Patients with Multiple Chronic Conditions (HEDIS FMC) | The percentage of emergency department (ED) visits for members ages 18 and older who have multiple high-risk chronic conditions who had a follow up service within 7 days of ED visit. | 56.50 % | NCQA National Average Medicare PPO |
| Follow-Up after ED Visit for Substance Use - 30-Day (HEDIS FUA) | The percentage of emergency department visits for members 13 years and older with a principal diagnosis of substance use disorder, or any diagnosis of drug overdose, for which there was a follow-up. | 49.40% | Medicaid 75th |
| Follow-Up after ED Visit for Mental Illness -30 Day (HEDIS FUM) | The percentage of emergency department visits for members 6 years and older with a principal diagnosis of mental illness or intentional self-harm, who had a follow-up visit for mental illness. | 73.12% | Medicaid 90th |
| Follow-Up After Hospitalization for Mental Illness (7 Days) (HEDIS FUH) | The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness or intentional self-harm diagnosis and who had a follow-up visit with a mental health provider. | 46.99% | Medicaid 75th |
Self-Reporting Dates and Deadlines
To qualify for the Population Health Model (PHM) payments and bonus payments, attributing primary care providers must complete mandatory online attestations and self-reporting in four areas: Hypertension control, Mental Health Screening, Social Determinants of Health Screening and Care Coordination activities.
For each data collection report, OneCare will send an email request prior to the due date.
Self-Reporting for Hypertension: Controlling high Blood Pressure (Quarterly)
| Frequency | Reporting Period | Email Request | Reminder Email | Reporting Deadline |
|---|---|---|---|---|
| Quarter 1 | March 1, 2024 – February 28, 2025 |
March 3, 2025 | March 10, 2025 | March 14, 2025 |
| Quarter 2 | June 1, 2024 – May 31, 2025 |
June 2, 2025 | June 9, 2025 | June 13, 2025 |
| Quarter 3 | September 1, 2024 – August 31, 2025 |
September 1, 2025 | September 8, 2025 | September 12, 2025 |
| Quarter 4 | January 1, 2025 – December 31, 2025 |
January 5, 2026 | January 12, 2026 | January 16, 2026 |
Self-Reporting for Mental Health Screening Initiative (Biannually):
| Frequency | Reporting Period | Email Request | Reminder Email | Reporting Deadline |
|---|---|---|---|---|
| Mid-year | January 1, 2025 – May 31, 2025 |
June 2, 2025 | June 9, 2025 | June 13, 2025 |
| End-of-Year | January 1, 2025 – December 31, 2025 |
January 5, 2026 | January 12, 2026 | January 16, 2026 |
Self-Reporting for Social Determinants of Health (Biannually):
| Frequency | Reporting Period | Email Request | Reminder Email | Reporting Deadline |
|---|---|---|---|---|
| Mid-year | January 1, 2025 – May 31, 2025 |
June 2, 2025 | June 9, 2025 | June 13, 2025 |
| End-of-Year | January 1, 2025 – December 31, 2025 |
January 5, 2026 | January 12, 2026 | January 16, 2026 |
Self-Reporting for Care Coordination (Triannually):
| Frequency | Reporting Period | Reminder Request | Reporting Deadline |
|---|---|---|---|
| Triannual 1 | January 1, 2025 – March 31, 2025 | April 4, 2025 | April 18, 2025 |
| Triannual 2 | April 1, 2025 – July 31, 2025 | August 8, 2025 | August 22, 2025 |
| Triannual 3 | August 1, 2025 – December 31, 2025 | January 19, 2026 | January 23, 2026 |
Updates for 2025: Payments
Here find upcoming updates to payment structures for 2025.
Population Health Model
Payments for Primary Care
- Fixed monthly base payment of $4.00 per member, per month (PMPM)
- Bonus payment amount of $5.25 PMPM divided equally across all applicable measures
- Monthly base payments are made to all providers from January through December 2025
- All providers have the opportunity to earn their full bonus potential based on PHM measure performance for the entire 2025 performance year
- Interim monthly PHM bonus payments begin in July 2025
- Year-end reconciliation of PHM measure performance and bonus payments in approximately April 2026 (based on performance from 1/1/2025 – 12/31/2025)
- PHM measures are applicable to all practices with one or more patients in the denominator
- Example: if a practice achieves 4 targets out of 7 applicable measures, PHM bonus rate would be $5.25/7 = $0 .75 x 4 = $3.00 PMPM, if a practice achieves 4 targets out of 4 applicable measures $5.25/4 = $1.31 x 4 = $5.25 PMPM
1 – Contingent upon satisfying Eligible Participant Obligations (see PHM Policy)
2 – Italicized date ranges are projected ranges for claims-based measures only, subject to data availability
3 – Performance-based (not guaranteed); performance and monthly bonus payment amount updated quarterly in July and October
4 – Full PHM bonus potential available ($3.15 PMPM X 12 mos. for PY24; $5.25 PMPM X 12 mos. for PY25)
Payments for Designated Agencies
- Monthly PMPM base payments based on each DA’s share of the total value of claims for care provided by DA’s to attributed lives under current ACO programs
- Bonus payments for meeting or exceeding FMC target in the PHM
- Additional $500k in PHM bonus funding for performance in DA specific measures (FUA, FUM, FUH)
Payment for Home Health and Hospice
- Monthly PMPM base payments based on agencies share of total value of claims for care provided by HHH agencies to attributed lives under current ACO programs
- Bonus payments for meeting or exceeding FMC target in the PHM
Payment for Area Agencies on Aging
-
Monthly PMPM payments based on each AAA’s relative share of assigned attributed lives in the AAA’s health service area
-
No bonus amount in 2025, money has been reallocated to “base” payments
Eligible Participant, Preferred Provider, and Collaborator Obligations:
- Participation in PHM and acceptance of PHM payments by Eligible Participants, Preferred Providers, and certain Collaborators constitutes an express agreement to align goals and priorities with the stated goals and priorities of OneCare, which includes, at minimum, working with OneCare to meet or exceed cost and quality targets under ACO Programs.
- All Eligible Participants shall provide a medical home for Assigned Attributed Lives, as defined in 18 V.S.A. § 704, as an indication the Participant is committed to managing their patient population with high-quality, cost-effective, team-based care.
- Eligible Participants, Preferred Providers, and Collaborators must actively participate in and report on care coordination activities, per the requirements set forth in policy and as outlined below, to receive any PHM payments under this policy. The guidance provided on the Provider Resource Center is overseen by OneCare’s Population Health Strategy Committee and will be updated with 2025 guidance on the OneCare website and promoted to participating members or upon request no later than November 1, 2024.
Updates for 2025: Provider Accountabilities
Here find upcoming updates to Provider Accountabilities for 2025.
Health Care Transformation and Innovation:
Promote strong performance in health care delivery in furtherance of achieving OneCare’s programmatic and strategic goals; embrace and demonstrate innovation in OneCare’s Population Health Model; integrate the “care model” (prevention, care coordination and care management), quality improvement, and health equity.
Provider Accountability: Health Equity
Health Related Social Needs/Social Determinants of Health Screening
- Incorporate SDOH screening into yearly patient visits using the CMS Health-Related Social Needs Screening Tool and electronic data entry in an EHR.
- Make SDOH screening results essential to holistic patient care.
- Electronically report SDOH screening rates to OneCare using the CMS tool (questions 1-15).
Mental Health Screening
- Participants must administer mental health screening annually for depression and suicide risk for patients twelve years of age and older
- A mental health follow-up plan for patients that screen positive must be documented
- Participants must self-report mental health screening rates to OneCare twice annually via electronic submission
Provider Accountability: Care Model and Quality
OneCare will provide performance reporting and improvement programs
- Actively pursue meeting targets in 75%+ of Population Health Model quality metrics for which the practice qualifies
Provider Accountability: Total Cost of Care Improvement
- Meet or exceed OneCare’s target for follow-up after emergency department visits for high-risk patients with multiple chronic conditions (HEDIS FMC)
Culture:
Promote an engaged and aligned network to achieve OneCare’s goals.
Provider Accountability: Good OneCare Citizenship
Commit to OneCare’s values and act in alignment with them.
Provider Accountability: Engagement
Participate in 50%+ of OneCare Value Based Care meetings annually:
- HSA Executive Consultations
- PHM Performance Review
- Care Coordination Meetings
Provider Accountability: Technology
By 1/1/25, use an Electronic Health Record compatible with CMS 2015 CEHRT standards and pursue advanced interoperability for data exchange with OneCare
Regional Clinical Representatives
In 2024, OneCare brought back a previous initiative and hired 10 regional clinical representatives (RCRs) from across Vermont’s health service areas. RCR goals are to:
- Champion for performance improvement in PHM measures
- Use data to identify practice needs for a performance improvement plan
- Support practice through partnership with a OneCare team member to identify opportunities for improvement
- Track and review performance improvement plans relative to PHM measures
Rick Dooley, PA-C
Thomas Chittenden Health Center
Alder Brook Family Health
Essex Pediatrics
Evergreen Family Health Lakeside Pediatrics
Richmond Family Medicine PLLC
Thomas Chittenden Health Center, PLC
Toby Sadkin, MD
Primary Care Health Partners
Cold Hollow Family Practice
Brattleboro Primary Care, 2 sites
Monarch Maples Pediatrics, 2 sites
Mt. Anthony Primary Care
St. Albans Primary Care
Timber Lane Pediatrics, 3 sites
Reija Rawle, MD
Southwestern Vermont Medical Center
Charleston Family Medicine
Springfield Practices, 4 sites
SVMC Deerfield Valley Campus
SVMC Medical Associates
SVMC Northshire Campus
SVMC Pediatric Services
SVMC Pownal Campus
Jeri Wohlberg, FNP
Northern Counties Health Care, Inc
Concord Health Center
Danville Health Center
Hardwick Health Center
Island Pond Health Center
Kingdom Internal Medicine
NVRH Corner Medicine
NVRH St. Johnsbury Pediatrics
St. Johnsbury Community Health Center
Lance Broy, MD
Lamoille Health Partners
Lamoille Health Family Medicine – Cambridge
Lamoille Health Family Medicine – Morrisville
Lamoille Health Family Medicine – Stowe
Lamoille Health Pediatrics
North Country
Kerry Goulette, PA-C
Community Health Centers Burlington
CHC Burlington (Riverside)
CHC Champlain Islands
CHC Essex
Good Health Center
South End Health Center
Winooski Family Health
Job Larson, MD
Community Health Centers of Burlington
Allen Pond Community Center
Brandon Medical Center
Castleton Family Health Center
CHCRR Pediatrics
Community Health North Main Street
Drs. Peter and lisa Hogenkamp
Mettowee Valley Family Health Center
Rutland Community Health Center
Shorewell Community Health Center
Pending
Brattleboro Memorial Hospital
Brattleboro Family Medicine
Brattleboro Internal Medicine
Maplewood Family Practice
Putney Health Center
Windham Family Practice
Keith Robinson, MD
Jeremiah Eckhaus, MD
Central Vermont Medical Center PHSO
University of Vermont Health Network PHSO
CVMC Adult Primary Care – Barre
CVMC Family Medicine – Berlin
CVMC Family Medicine – Mad River
CVMC Family Medicine – Main Campus
CVMC Adult Primary Care – Waterbury CVMC Green Mountain Family Medicine – Montpelier
CVMC Pediatrics Primary Care – Berlin PMC Primary Care – Brandon
PMC Primary Care – Middlebury
PMC Primary Care – Vergennes
UVM Children’s Hospital Pediatrics
UVMMC Adult Primary Care – Burlington
UVMMC Adult Primary Care – Essex
UVMMC Adult Primary Care – South Burlington
UVMMC Adult Primary Care – Williston
UVMMC Family Medicine – Colchester
UVMMC Family Medicine – Hinesburg
UVMMC Family Medicine – Milton
UVMMC Family Medicine – South Burlington