Health Insurance Exchanges and Patient-Centered Medical Home Initiatives
*Chart updated June 5, 2014
Patient-centered medical homes (PCMHs) focus on providing team-based primary care in partnership with patients and families. The medical home is best described as a model or philosophy of primary care that is patient-centered, comprehensive, coordinated, and accessible with a commitment to ongoing quality improvements in care delivery and safety. States can increase access to coordinated patient-centered care by building high-performing medical homes. This chart documents PCMH references in 2014 state standards for qualified health plans (QHPs), the private insurance plans sold through health insurance exchanges. The chart also highlights exchange model type and states implementing active purchasing strategies.
Like all State Refor(u)m research, this chart is a collaborative effort with you, the user. State Refor(u)m captures the health reform comments, documents, and links submitted by health policy thinkers and doers all over the country. And our team periodically supplements, analyzes, and compiles this key content.
Know of something we should add to this compilation? Eager to update a fact we’ve included? Your feedback is central to our ongoing, real-time analytical process, so tell us in a comment, or email the author with your suggestion. Lisabeth can be reached at lbuelt@pcpcc.org.
Like all State Refor(u)m research, this chart is a collaborative effort with you, the user. State Refor(u)m captures the health reform comments, documents, and links submitted by health policy thinkers and doers all over the country. And our team periodically supplements, analyzes, and compiles this key content.
Know of something we should add to this compilation? Eager to update a fact we’ve included? Your feedback is central to our ongoing, real-time analytical process, so tell us in a comment, or email the author with your suggestion. Lisabeth can be reached at lbuelt@pcpcc.org.
| State | Exchange Model [1] | PCMH Referenced in 2014 State Standards of Exchange Qualified Health Plans | States Implementing Active Purchasing [2][3] |
|---|---|---|---|
| AL | FFE | ||
| AK | FFE | ||
| AZ | FFE | ||
| AR | SPE | Arkansas state law requires plans offered on the exchange to participate in the Arkansas Payment Improvement Initiative, which includes assignment to a primary care clinician, support for PCMH and access of clinical performance data for providers. | |
| CA | SBE | California’s QHP contract encourages issuers selling plans in the Marketplace to assist enrollees in selecting a primary care provider, federally qualified health center or a PCMH within 60 days of enrollment. | State acts as an active purchaser. |
| CO | SBE | ||
| CT | SBE | Connecticut’s QHP solicitation encourages issuers to submit non-standardized plans including those that utilize different care management models (e.g., PCMHs, community health teams). | State has legislation that allows active purchasing, but is currently operating under the clearinghouse model. |
| DC | SBE | State has legislation that allows active purchasing, but is currently operating under the clearinghouse model. | |
| DE | SPE | Delaware’s QHP guide requires issuers to participate in state quality improvement workgroups on various quality improvement strategies and metrics including payment structures to improve health outcomes, PCMH models, and technology and data analytics that support care coordination and improved quality and outcomes. | |
| FL | FFE | ||
| GA | FFE | ||
| HI | SBE | ||
| ID | SBE | ||
| IL | SPE | ||
| IN | FFE | ||
| IA | SPE | ||
| KS | FFE | ||
| KY | SBE | ||
| LA | FFE | ||
| ME | FFE | ||
| MD | SBE | Maryland insurance regulations require delivery of benefits for individuals with chronic conditions, serious illnesses, or complex health care needs who agree to participate in a PCMH program. Associated care coordination costs are covered such as: liaison services between patients and the care team; use of care plans; patient and family education on health care needs; and assistance with coordination of care across care teams and the medical neighborhood. | The insurance marketplace currently functions under the clearinghouse model, with the option of moving toward the active purchasing model in 2016. |
| MA | SBE | ||
| MI | FFE | ||
| MI | FFE | ||
| MN | SBE | ||
| MS | FFE | ||
| MO | FFE | ||
| MT | FFE | ||
| NE | FFE | ||
| NV | SBE | ||
| NH | SPE | ||
| NJ | FFE | ||
| NM | SBE | ||
| NY | SBE | ||
| NC | FFE | ||
| ND | FFE | ||
| OH | FFE | ||
| OK | FFE | ||
| OR | SBE | State acts as an active purchaser. | |
| PA | FFE | ||
| RI | SBE | State acts as an active purchaser. | |
| SC | FFE | ||
| SD | FFE | ||
| TN | FFE | ||
| TX | FFE | ||
| UT | FFE | ||
| VT | SBE | Vermont’s RFP for QHPs encourages issuers to include innovative preventive care models in its non-standardized plan designs such as Advanced Primary Care Practices, PCMHs and Community Health Teams. | State acts as an active purchaser. |
| VA | FFE | ||
| WA | SBE | Washington Healthplanfinder guidance requires that a direct primary care medical home must be integrated with an issuer’s qualified health plan. | |
| WV | SPE | ||
| WI | FFE | ||
| WY | FFE | ||
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Notes:
[1] The exchange model column references information from State Refor(u)m’s Where States Stand on Exchanges map, available at https://www.statereforum.org/where-states-stand-on-exchanges.
[3] We define active purchasing broadly here. It can mean any or all of the following strategies: 1) adding standards for plan certification above the federal requirements and then certifying all plans that meet these standards; 2) selective contracting with where the exchange limits the number of plans participating by using selective criteria; and 3) negotiating price with plans individually and deciding to exclude plans.
Produced by leadership of the Advocacy and Public Policy Center at the Patient-Centered Primary Care Collaborative, with contributions from NASHP’s Julien Nagarajan and Rachel Dolan.
About the Patient-Centered Primary Care Collaborative
Founded in 2006, the Patient-Centered Primary Care Collaborative (PCPCC) is a national not-for-profit organization dedicated to advancing an effective and efficient health system built on a strong foundation of primary care and the patient-centered medical home (PCMH). The PCPCC achieves its mission through the work of our five Stakeholder Centers, led by experts and thought leaders who are dedicated to transforming the U.S. health care system through delivery reform, payment reform, patient engagement, and employee benefit redesign. Today, PCPCC’s membership represents more than 1,000 medical home stakeholders and supporters throughout the U.S.
- FFE: Federally-facilitated Exchange
- SBE: State-based Exchange
- SPE: State Partnership Exchange
[3] We define active purchasing broadly here. It can mean any or all of the following strategies: 1) adding standards for plan certification above the federal requirements and then certifying all plans that meet these standards; 2) selective contracting with where the exchange limits the number of plans participating by using selective criteria; and 3) negotiating price with plans individually and deciding to exclude plans.
Produced by leadership of the Advocacy and Public Policy Center at the Patient-Centered Primary Care Collaborative, with contributions from NASHP’s Julien Nagarajan and Rachel Dolan.
About the Patient-Centered Primary Care Collaborative
Founded in 2006, the Patient-Centered Primary Care Collaborative (PCPCC) is a national not-for-profit organization dedicated to advancing an effective and efficient health system built on a strong foundation of primary care and the patient-centered medical home (PCMH). The PCPCC achieves its mission through the work of our five Stakeholder Centers, led by experts and thought leaders who are dedicated to transforming the U.S. health care system through delivery reform, payment reform, patient engagement, and employee benefit redesign. Today, PCPCC’s membership represents more than 1,000 medical home stakeholders and supporters throughout the U.S.
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