Alternative Payment Models (APMs) are designed to improve patient experiences and health outcomes while reducing cost. APMs promote child-centered care by linking payment to the delivery of high-quality and cost-efficient care. They also give practices the flexibility to best meet the needs of their patients. This includes providing services that may not traditionally be reimbursed in fee-for-service payment approaches (e.g., coordinating care for social needs).

The NC InCK APM was co-designed by leaders from NC Medicaid, all five Prepaid Health Plans (PHPs), clinically integrated networks (CINs) in NC InCK's five counties, and other stakeholders. The NC InCK APM launched in January 2023. It is available to practices that provide care for Medicaid Standard Plan-insured children birth to age 20 in Standard Plans in Alamance, Orange, Durham, Granville, and Vance counties. NC InCK's APM includes incentives for reporting and achieving goals in the areas of:

• • Kindergarten readiness

• • Housing instability and food insecurity

• • Completion of a Shared Action Plan for children with higher needs

• • Screening for clinical depression and documenting a follow-up plan

• • Emergency department utilization

• • Disparities by race and ethnicity in well child visit completion in the first 30 months of life

The APM is an opportunity for increased resources and flexibility for practices to support innovative approaches to caring for children and families. Providers utilizing the NC InCK APM will receive:

• The opportunity for increased resources. Financial incentives will be available for activities that promote child well-being, such as promoting Kindergarten Readiness, and screening for food insecurity and housing instability. In addition, providers will be invited to participate in NC InCK integrated care case rounds and will receive resource guides and recommendations for how to best meet the integrated care needs of patients.
• More information about the kids you care for. NC InCK, in partnership with NC Medicaid, will provide regular reports to practices on actionable data on novel child-centered measures, such as rates of Kindergarten Readiness, food insecurity, and housing instability.

All children and youth who are insured by a Medicaid Standard Plan and who live in Alamance, Durham, Orange, Granville, or Vance County from birth through age 20 are included in the NC InCK APM. Children are included in the APM regardless of whether they qualify for NC InCK care management. Children enrolled in Medicaid Direct or a Tailored Plan are not included in the NC InCK APM.

All children birth through age five (up until the child’s sixth birthday) are eligible for the Kindergarten Readiness Promotion Bundle.

NC InCK beneficiaries are attributed to plans, CINs, and practices based on Medicaid attribution logic. The NC Department of Health Benefits sends a monthly NC InCK attributed member list, which also includes children’s Service Integration Level (SIL) assignments, to PHPs. PHPs then provide this information to CINs for distribution to individual practices.

The NC InCK APM is a 5-year, targeted incentive program in the five NC InCK counties. The NC InCK APM launched in Q1 of 2023 and will run through December 2026. The NC InCK APM includes AMH incentive payments through Prepaid Health Plan contracts, which are linked to reporting and performance against benchmark targets. The NC InCK APM is an upside-only model, meaning participants are not subject to shared losses or payment penalties.

"Aware" above is defined as an NC InCK performance measure not explicitly linked to an incentive payment, but shared with health plans and providers for awareness of quality measure performance

* These two rates collectively are referred to as "Well-Child Visits in the First 30 Months of Life (W30)" in HEDIS specifications.

Providers and practices will receive reports on their patients - both for their full population of children attributed to NC InCK and for children assigned to each PHP. Performance reports will be stratified by race, ethnicity, and county to allow insights on potential disparities.

Generating final performance reports takes several steps. First, the NC Division of Health Benefits (DHB) sends data to each of the Medicaid plans. Then, the plans send performance data to each of the participating clinically integrated networks (CINs). Lastly, the CINs combine performance reports from all of the plans to generate the final practice-level performance reports. CINs then share these reports with both the Medicaid plans and individual clinics. The report generation timeline for Performance Year 2024 is shown below.

Beginning in 2023, NC Medicaid will determine whether practices are achieving performance benchmarks for the NC InCK APM measures. Please refer to NC InCK Performance Measure Technical Specifications Manual for detailed benchmark targets. A practice's performance on each measure will be assessed across all of their NC InCK-attributed children - across all PHPs with whom they are contracted. This type of assessment that combines or pools together all children in the Standard Plans is called pooled performance measurement.

Pooled performance rates will be calculated across all plans with whom an Advanced Medical Home Tier 3 (AMH) is contracted for the NC InCK APM, regardless of the specifics of a plan's APM structure. For example, if a given AMH is contracted with United, Wellcare, and Healthy Blue for the NC InCK APM, their calculated rates will include members from all three plans. If this pooled performance rate meets a given benchmark, the AMH will receive the appropriate quality payment from each of the three plans. Similarly, United is not attaching incentive payments to NC InCK's W30 measure, but United members will still be included when calculating an AMH's rate for that measure. This helps address concerns about small denominators. 

Performance rates and baselines are calculated at the practice/AMH level. That is, individual AMHs will either meet or not meet the benchmark for each measure, and payments will be calculated based on that AMH's numerator, denominator, or full NC InCK population. This is consistent with the approach for other Medicaid VBP arrangements. DHB is not dictating the specifics of how funds should flow or what the payment breakdown should be between CINs and AMHs.

Plans will receive a pooled performance practice level report (from CINs) that includes the number of that plan's beneficiaries that were in the numerator and denominator for each measure at each AMH as well as the AMH's performance and baseline for the pooled measure. The plan will use this to determine the actual incentive payment. Some plans will multiply by numerator, some by denominator, some will not pay at all for a measure or two. All plans will have the data pieces they need to calculate the incentives based on their particular contracts.

Payment on any one performance measure is independent of performance on others.

Incentive payment is applied once the threshold is met as outlined in the table below:

*These two rates collectively are referred to as "Well-Child Visits in the First 30 Months of Life (W30)" in HEDIS specifications.

**With no existing disparity (defined as an AMH's Black/African American rate for this measure being no more than 2% below the white rate), an AMH will qualify for Tier 1 payment if their overall rate meets or exceeds the Standard Plan target for this measure.

CINs (Duke Connected Care, UNC Health Alliance, and Community Care Physician Network) have negotiated payment rates with the prepaid health plans with which they have chosen to contract. Funds received for achieving benchmarks will be distributed from prepaid health plans to CINs. Clinics can request information from their affiliated CIN regarding how much money they may receive.

Yes. On April 1, 2023, the ICD-10-CM replaced Z59.1 (Inadequate Housing) with a set of more specific codes. Providers should now use Z59.10 in place of Z59.1 to document needs related to inadequate housing for the NC InCK APM. More information can be found at this link.

Some measures in the APM, such as the Kindergarten Readiness Promotion Bundle (KRPB) and Screening for Food Insecurity and Housing Instability, include making referrals. Many of these referrals do not involve obtaining medical services, therefore, a formal referral order is not a requirement. For current NC InCK APM measures, a provider recommendation may also count as a referral. For example, if you are seeing a 12-month-old for a well child visit and verbally recommend a reading program at a local library, that recommendation counts as a referral to a community-based literacy program, which is a component of the KRPB. We strongly encourage that providers consider pairing verbal recommendations with additional action, such as use of handouts like fliers or brochures, to supplement recommendations. Using the above example, giving a verbal recommendation for a local library reading program along with a flier containing information about this program is considered a stronger recommendation than verbal recommendation alone. To receive credit with NC InCK’s APM for a referral, the provider must discuss the referral with the patient and/or family and it must be clearly documented in the encounter on the date the referral was made. 

Yes, this can still count as a referral, as long as it is a referral addressing a need as described in the APM measures.  We encourage practices to establish a standardized workflow that includes support and admin staff to strengthen referral processes and improve service delivery for children.  Many practices may choose to design referral orders and processes within their Electronic Health Record (EHR), which often includes routing electronic referrals to support staff who then manages these referrals. Regardless of how a referral is handled within your clinic or healthcare system, you must clearly document the referral in the encounter on the date the referral was made to receive credit with NC InCK’s APM.