FAQ on the CPC+ Initiative

Frequently Asked Questions About the Comprehensive Primary Care Plus Initiative

Practice Eligibility and Participation

1. What are the eligibility requirements to apply for CPC+? 

CPC+ is only open to primary care, specifically family medicine, internal medicine, and geriatrics. The model is open to any practice size. Some basic eligibility requirements can help determine if CPC+ is a fit for your practice:

  • Tracks 1 & 2: The practice must be located in a Round 2 CPC+ region.
  • Tracks 1 & 2: The practice must have at least 125 attributed Medicare Part B fee for service (FFS) beneficiaries. This does not include patients with Medicare Advantage.
  • Tracks 1 & 2: The practice should have approximately 45% or more of current revenue generated from CPC+ payer partners and Medicare fee for service.
  • Tracks 1 & 2: The practice uses CEHRT.
  • Tracks 1& 2: The practice does not charge patients a retainer or practice membership fee.
  • Track 1 & 2: The practice has existing care delivery activities which include: patients assigned to provider panel, 24/7 access for patients, and support for quality improvement activities.
  • Track 2 only: The practice has existing care delivery activities which include: following up with patients after emergency department (ED) or hospital discharge and implementing a process to link patients to community based resources.
  • Track 2 only: The practice provides, with its CPC+ application, a letter of support(innovation.cms.gov) from a health IT vendor that outlines the vendor’s commitment to support the practice in optimizing health IT. 

2. Are any practice types ineligible for CPC+?

The following practices are not eligible to apply:

  • Pediatric Practices
  • Concierge and Direct Primary Care Practices
  • Rural Health Clinics
  • Federally Qualified Health Centers
  • Practices participating in certain alternative payment models. See question 4 »

3. What patients will be attributed to me for CPC+?

Medicare Advantage patients do not count toward the 125 Medicare FFS beneficiaries required for CPC+ eligibility. Attribution of Medicare FFS beneficiaries is based on a two-year look-back at the claims history of patients that are on your practice roster who visited CPC+ clinicians. Not all Medicare FFS beneficiaries your practice cares for will be attributed to your practice. CMS will attribute to a CPC+ practice those Medicare FFS beneficiaries for whom its clinicians either:

  • provided the plurality of primary care services in the most recently available 24-month period (based on allowed charges), or
  • served as the most recent provider of chronic care management services. 

If a beneficiary has an equal number of claims for primary care services to more than one CPC+ practice, the beneficiary will be attributed to the practice with the most recent claim for a primary care service. The CPC+ Payment Methodology Paper(innovation.cms.gov) provides additional details on attribution.

4. Can I participate in other alternative payment models (APMs) and CPC+?

Participation in the following models is allowed along with CPC+ participation:

  • Medicare Shared Savings Program ACO Tracks 1, 2 and 3; see question 12 »
  • Model 2 and Model 3 of the Bundled Payments for Care Improvement Initiative and the Comprehensive Care for Joint Replacement model
  • Millions Hearts Cardiovascular Disease Risk Reduction model
  • Accountable Health Communities model
  • State Innovation Model (SIM)
  • Multi-payer Advanced Primary Care Practice demonstration
  • AHRQ Evidence NOW initiative

If you participate in the following excluded programs, your practice will not be allowed to also participate in CPC+:

  • ACO Investment Model (AIM)
  • Next Generation ACO
  • Independence at Home
  • Other shared savings programs
  • Transforming Clinical Practice initiative (TCPi)

Participation in the excluded programs does not preclude you from applying for CPC+. The application will ask the practice to identify the programs in which it is currently participating and indicate your willingness to withdraw from that program if selected for CPC+.

5. How does CPC+ Round 2 differ from CPC+ Round 1? 

The CPC+ model, including model design and practice eligibility, will be the same in Round 1 and Round 2, with one exception: CMS will randomize eligible Round 2 practice applicants, placing practices in either the CPC+ intervention group or the comparison group. The randomized trial design of CPC+ Round 2 seeks to strengthen the evaluation of the model. Those practices placed into the comparison group will not receive the CPC+ payments, will not participate in the learning communities, and will not have implementation requirements. Practices in the comparison group will be asked to sign a letter of agreement and receive $5,000 annually for participation in evaluation activities.

6. If I am a part of a large health system with many practices, can my practice apply if other practices in my system do not?

Yes, CMS encourages all eligible practices in selected regions to apply. Practices owned by health systems will be required to identify the practice name and TIN of each primary care practice within the system that is applying to CPC+. Each practice owned by a health system must provide a signed letter by system leadership that commits to segregate CPC+ funds. Because CPC+ is a practice-level intervention, every practice applying to CPC+ must submit its own application and will be evaluated individually at the practice level for eligibility. See question 13 for more information on the impact of your practice’s participation in CPC+ in a large health system.

7. For a large system with many practices involved in CPC+, can one practitioner or staff member attend required learning events as a representative for the whole system? 

No, each CPC+ practice must designate a Learning Lead, because learning is intended to happen at the practice level, not at the larger system level.

Health IT

8. Is a letter of support required from my EHR vendor? 

If you are applying to participate in Track 2 of CPC+, you must have a letter of support from your health IT vendor that outlines the vendor’s commitment to support the practice in optimizing health IT.

9. What version of CEHRT does CPC+ require? 

Round 1 practices may use 2014 Edition or 2015 Edition technology in 2017. However, starting in 2018, Round 1 and Round 2 practices must use 2015 Edition technology. 

CPC+ and the Quality Payment Program (QPP)

10. Is CPC+ an Advanced Alternative Payment Model (AAPM) under the Medicare QPP? Am I excluded from the Merit-based Incentive Payment System (MIPS) based on my CPC+ participation? 

Both tracks of CPC+ are considered AAPMs. Your status in MIPS depends on your level of participation: 

CPC+ makes it possible to become a qualifying participant (QP) for the AAPM track if you meet the QP thresholds. To meet the QP threshold, CPC+ practices must either receive 25% of Medicare Part B FFS payments through the AAPM or see 20% of Medicare Part B patients through the AAPM.

Once CMS identifies you as an AAPM QP, you are exempt from MIPS reporting requirements and payment adjustments and qualify for the 5% lump sum bonus. You will still receive CPC+ payments and Medicare FFS payments.

If you do not meet the QP threshold described above, then you will participate in QPP as an eligible clinician (EC) in a MIPS APM and will be subject to MIPS reporting requirements. CPC+ participants will be evaluated for MIPS at the practice level (i.e., the MIPS entity) and Medicare payments will be adjusted based on performance in MIPS categories. You will receive CPC+ payments, Medicare FFS payments and updates, and MIPS payment adjustments. 

Beginning in 2018 CPC+ practices whose parent organization has more than 50 clinicians will not be considered AAPMs and will not be able to reach QP status under CPC+.

11. If I’m in a MIPS APM under CPC+ how will my MIPS score be calculated? 

Your MIPS score will be calculated as follows in 2017:

  • The quality category will be 0% of your MIPS score due to operational constraints that prevent CMS from being able to use CPC+ quality measures for MIPS in 2017. (This will change in 2018.)
  • The cost category will be 0% of your MIPS score. (This will change in 2018)
  • The advancing care information (ACI) category will be 75% of your MIPS score. (This will decrease in 2018)
  • The improvement activities (IA) category will be 25% of your MIPS score. CMS will automatically assign a score of 100% for the IA category in 2017.

The weights of MIPS categories will change in future years. This FAQ will be updated to reflect changes from the 2018 final rule.

12. My practice site is in CPC+ and our organization (TIN) is also in MSSP ACO Track 1. How will the two programs interact under the Quality Payment Program (QPP)?

If you are in an MSSP ACO and CPC+, you will participate in QPP according to your MSSP ACO track, not CPC+--the MSSP ACO takes precedence over CPC+ for the purpose of QPP. That means eligibility to be an AAPM QP is based on the MSSP ACO track, regardless of CPC+ participation. MSSP Track 2 and 3 are both AAPMs. MSSP Track 1 is a MIPS APM.

Because MSSP Track 1 is a MIPS APM, you will not be able to reach AAPM QP status, and will therefore, be subject to MIPS payment adjustments. MIPS APMs are scored using the APM scoring standard, which uses ACO-related performance data to streamline reporting. MIPS scores will be aggregated to the MSSP ACO entity level and all ECs in your MSSP ACO will receive the same MIPS final score. 

Your payment incentives for cost and quality under your MSSP ACO contract will not change as a result of your participation in CPC+. CPC+ practices participating in any MSSP track will receive shared saving/losses through their ACOs in lieu of CPC+ performance-based incentive payments. However, you will still receive the CPC+ Care Management Fee (per member per month) and Medicare FFS payments (full or hybrid, depending on the CPC+ track in which you are participating). You will still need to meet quality reporting requirements of CPC+ to receive these payments (i.e., at least 9 of 14 eCQMs).

13. There are non-CPC+ participants in my organization. How are they impacted by my participation in CPC+?

If there are non-CPC+ participants in your organization (TIN), they will not be impacted by your CPC+ participation; that is, your QP status and MIPS score will not affect non-CPC+ participants. Non-participants will need to report to MIPS under the generally applicable MIPS requirements for reporting as an individual or group. If they report as a group, then the organization (TIN) may include data from the CPC+ participants, if desired. However, CPC+ participants will receive their MIPS final score based on their CPC+ participation, as described in questions 10 and 12 above. 

14. My practice has six clinicians and is participating in CPC+. Our organization (TIN) has 80 clinicians. Will I be able to reach QP status under CPC+?

You may be able to reach QP status in 2017, but not thereafter. Beginning in 2018, organizations with more than 50 clinicians can still participate in CPC+, but will not be considered AAPMs. If your organization has more than 50 clinicians, you will not be able to reach QP status under CPC+ beginning in 2018.

Billing and Payment

15. Where can I find a listing of payers participating in CPC+?  

Payers participating in CPC+ Round 1(innovation.cms.gov) and Round 2(innovation.cms.gov) regions are available on the CMS website. 

16. Can practices use their CPC+ Care Management Fees (CMF) to pay for health IT needs? 

No. You may not use CMS CMFs paid by Medicare to pay for e-health devices, monitoring equipment, health IT/software, upgrades, modules, and/or devices. The use of CMS CMFs on any sort of health IT is prohibited.

You can only use CMS CMFs for performing care delivery requirements, such as wages for new or existing staff (e.g., care manager, care coordinator, pharmacist) who perform care delivery requirements, for care delivery tools related to care delivery requirements (e.g., shared decision making aids), and for training and travel directly related to the implementation of care delivery requirements. 

17. Can CPC+ practices bill the cognitive care codes (CCM, TCM, AWV and Behavioral Health) for CPC+ attributed Medicare beneficiaries? 

The following table outlines the allowable cognitive care billing for attributed Medicare FFS beneficiaries for CPC+ practices. Practices may bill all of these codes for their unattributed beneficiaries. In some cases, practices will be allowed to bill the codes for their CPC+ attributed beneficiaries when they do not pay for the same services as the CPC+ Care management Fee. You can find more information on care management codes in the Debits for Duplication of Services section the CPC+ Payment Methodology paper(innovation.cms.gov).

Codes

Description

May CPC+ Practices Bill for Attributed Medicare FFS Beneficiaries?

99487, 99489

Chronic Care Management

No

G0502, G0503, G0504

Collaborative Care Model

Yes

G0505

Cognition and functional assessment for patient with cognitive impairment 

Yes

G0506

Assessment/care planning for patients requiring CCM services

No

G0507

Care management services for behavioral health conditions

No

99358, 99359

Prolonged non-face-to-face evaluation and management services

No

99495, 99496

Transitional Care Management

Yes

G0438, G0439

Annual Wellness Visit (Initial and Subsequent)

Yes

18. How will the care management fee risk scores be determined for my CPC+ patients?  

Care management fee risk scores for Medicare patients are determined using the CMS Hierarchical Conditions Category (HCC) prospective risk adjustment model. The CMS-HCC model produces a risk score that measures a person’s health status relative to an average of 1.0, as applied to expected medical expenditures. For example, a risk score of 2.0 is expected to incur medical expenses twice that of the average, while a score of 0.5 is expected to incur medical expenditures half that of the average. Final risk scores are calculated by CMS and are generally available 16-18 months after the close of the base year. CMS will update risk score data in the third payment quarter of each year.

Learn more in the CPC+ Payment Methodology paper »(innovation.cms.gov)

19. How do CMS HCC risk scores relate to risk-stratified care management (RSCM)?  

All Medicare FFS beneficiaries attributed to a CPC+ practice will be assigned to one of four risk tiers for Track 1 or one of five risk tiers for Track 2 for that CPC+ practice’s region. Each risk tier corresponds to a specific monthly CMF payment, with higher risk tiers associated with higher beneficiary risk and higher CMF payments. Beneficiary risk will be determined by the CMS HCC risk adjustment model. For Track 2 beneficiaries, risk tier will also be determined by a diagnosis of dementia.

Risk-stratified care management is the process of assigning a health risk status to empaneled patients and using this status to direct and improve patient care. Practices can use the list of attributed Medicare FFS beneficiaries and their related risk scores as a starting point for patient empanelment and risk-stratified care management.

Learn more about RSCM and access the AAFP’s RSCM tool »

20. How frequently are practices’ patient attribution, risk scores, and Care Management Fees (CMFs) adjusted? 

CMS adjusts practices’ risk scores and CMFs annually. Beneficiary attribution is adjusted quarterly. As such, even if a practice’s beneficiary roster changes from quarter to quarter, the beneficiaries will have the same risk score throughout the year.

Quality Measures

21. Will quality measures be calculated for all of a practice’s patients, or just its attributed Medicare FFS patients?

Quality measures will apply to all patients at a practice. Utilization measures, however, are specific to Medicare FFS beneficiaries.

22. What measures do CPC+ practices report? 

Find out more about CPC+ quality measure reporting in this overview of 2017 requirements(innovation.cms.gov) from CMS.

CPC+ Performance-based Incentive Payments

23. Is it possible I may have to repay performance-based incentive payments I receive? 

Yes, this is the only portion of the CPC+ payments that are at risk. CMS will prospectively pay a performance-based incentive payment, which practices may keep if they meet annual performance thresholds. Practices that do not meet the annual thresholds would be required to repay all or a portion of the prepaid amount—your practice is “at risk” for this amount.