For purposes of this article, the following definitions apply:
(a) “Alternative payment methodology” (APM) has the same meaning as specified in Section 1396a(bb)(6) of Title 42 of the United States Code.
(b) “APM aid category” means a Medi-Cal category of aid designated by the department. For all its APM enrollees in an APM aid category, a participating FQHC site shall receive compensation as described under the APM pilot project. The APM aid categories may include, but are not limited to, all of the following categories of aid:
(1) Adults.
(2) Children.
(3) Seniors and persons with disabilities.
(4) The adult expansion population eligible pursuant to Section 14005.60, to the extent the department determines, in consultation with health plans and interested FQHCs, that sufficient data is available to allow for inclusion of this population in the APM pilot project. This paragraph shall not be construed to prohibit inclusion of the adult expansion population in the APM pilot project on a date subsequent to initial authorization pursuant to subdivision (a) of Section 14138.12.
(c) “APM enrollee” means a member who is assigned by a principal health plan or subcontracting payer to a participating FQHC for primary care services and who is within one of the designated APM aid categories.
(d) “APM pilot project” means the pilot project authorized by this article.
(e) “APM scope of services” means the scope of services for a participating FQHC for which its per-visit rate was determined pursuant to Section 14132.100, but only to the extent those services are covered pursuant to the contract between the department and the applicable principal health plan.
(f) “APM supplemental capitation” means an additional, APM aid category-specific, PMPM amount that is paid by the department to a principal health plan having one or more participating FQHCs in its provider network.
(g) “Clinic-specific PMPM” means the monthly, per assigned member, capitated amount the principal health plan or subcontracting payer is required to pay to the participating FQHC for the APM scope of services. The clinic-specific PMPM is exclusive of any incentive payments and shall be developed to reflect the amount the participating FQHC would have received under the prospective payment system methodology set forth in Section 14132.100.
(h) “FQHC” means any community or public “federally qualified health center,” as defined in Section 1396d(l)(2)(B) of Title 42 of the United States Code and providing services as defined in Section 1396d(a)(2)(C) of Title 42 of the United States Code.
(i) “Member” means a Medi-Cal beneficiary who is enrolled with a principal health plan or subcontracting payer.
(j) “Participating FQHC” means an FQHC participating in the APM pilot project at one or more of the FQHC’s sites. “Participating FQHC” also refers to an FQHC’s site that is participating in the APM pilot project.
(k) “PMPM” and “per member per month” both mean a monthly payment made for providing or arranging health care services for a member and may refer to a payment by the department to a principal health plan, or by a principal health plan to a subcontracting payer, or by a principal health plan or subcontracting payer to an FQHC, or from and to other entities as specified in this article.
(l) “Principal health plan” means an organization or entity that enters into a contract with the department pursuant to Article 2.7 (commencing with Section 14087.3), Article 2.8 (commencing with Section 14087.5), Article 2.81 (commencing with Section 14087.96), Article 2.82 (commencing with Section 14087.98), Article 2.91 (commencing with Section 14089), or Chapter 8 (commencing with Section 14200), to provide or arrange for the care of Medi-Cal beneficiaries within a county in which the APM pilot project is implemented.
(m) “Subcontracting payer” means an organization or entity that subcontracts with a principal health plan to provide or arrange for the care of its members and contains one or more participating FQHCs in its provider network.
(n) “Traditional encounter” means a face-to-face encounter that is recognized as a billable visit, as described in subdivision (g) of Section 14132.100.
(o) “Traditional wrap-around payment” means the supplemental payments payable to an FQHC in the absence of the APM pilot project with respect to services provided to Medi-Cal managed care enrollees, which are made by the department pursuant to subdivision (e) of Section 14087.325 and subdivision (h) of Section 14132.100.
(Added by Stats. 2015, Ch. 760, Sec. 1. (SB 147) Effective January 1, 2016.)
Last modified: October 25, 2018