Provider Resource Center

• July 2024 Need-to-Know from Your ACO
• August 2024 Need-to-Know from Your ACO
• September 2024 Need-to-Know from Your ACO

• Network organizations participating in the PHM submit triannual care coordination reporting inclusive of a list of care managed attributed lives and interventions.
• Organizations are notified of audit and validation template is provided.
• Selected organizations are audited on 10 individuals or the maximum number available.
• Target areas of validation audit per care managed individual:
  • Evidence of lead care coordinator
  • Evidence of shared care plan
  • Evidence of cross organizational collaboration if so reported
  • Evidence of encounter frequency
  • Evidence of a care team conference if so reported
• Organizations have four weeks to complete and submit documentation requested.
• Organizations are responsible for providing adequate evidence in 90% or more of targeted areas.
• If an organization is not able to provide 90% of adequate evidence, they will be subject to additional action based on the percentage of evidence provided.
• If the organization is not responsive or does not demonstrate improvement, PHM payments may be affected.

• For Performance Year 2024, the Eligible Participant PHM base payment amount is $4.25 per Assigned Attributed Life per month.
• For Performance Year 2024, the PHM bonus payment amount will be $0.50 per Assigned Attributed Life per month per PHM measure for a total of up to $2.50 PMPM for achieving all PHM measures per practice type.
• While PHM payments to Eligible Participants are issued at the TIN level, performance is measured, and payments are calculated at the Practice level when practicable. If a PHM Measure has any N>=10, OneCare will measure performance and pay per policy. For N<10 for a quarterly PHM report/payment, OneCare will perform as if the practice missed the quarterly PHM Measure target. During the annual, full Program Year reconciliation, OneCare will allow any practice with N>=10 for the full year to recoup any previously missed PHM bonus payments (if earned). If N<10 for the full year, then any PHM bonus dollars for that (those) measure(s) will be redistributed to all other PHM Measures with N>=10 and paid per policy.

In approximately May 2025, OneCare will assess all Eligible Participants’ performance for the entirety of Calendar Year 2024 for all applicable PHM measures. Eligible Participants that meet the performance target for the Performance Year for any PHM measure will earn all previously unearned 2024 PHM bonus payments per measure.

• Performance is measured and payments are calculated at the HSA level, while payments are issued at the TIN level.
• Seventy-five percent (75%) of budgeted PHM funds for each entity type including Home Health and Hospice Agencies, Designated Agencies, and Area Agencies on Aging, will be distributed to eligible agencies as monthly PHM base payments. PHM incentive payments to these Preferred Providers and Collaborators are issued at the TIN level. Performance is measured and payments are calculated at the HSA level.
• Twenty-five percent (25%) of budgeted PHM funds for the above entities will be distributed as annual PHM bonus payments based on meeting or exceeding the performance targets for the Performance Year for any applicable PHM measures. Bonus payments will be distributed during May or June 2025 after sufficient claims runout following the end of the Performance Year.

• 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, within the this document, the 2024 OneCare Value-Based Care Guidance Document, to receive any PHM payments under this policy. The 2024 OneCare Value-Based Care Guidance Document is overseen by OneCare’s Population Health Strategy Committee and will be made available on the OneCare’s Portal available to participating members or upon request no later than November 1, 2023.
• Eligible Participants, Preferred Providers, and Collaborators must actively participate in performance improvement activities in alignment with PHM Measures until performance targets are achieved or exceeded. See the table above for Program Year 2024 PHM Measures, with measure applicability by provider/agency type, measurement level (Practice or HSA), and data source by measure.

• Report your concern to your organization’s compliance or privacy officer
• Report the concern through the OneCare Compliance Hotline.