Here’s how it works

Financial incentives are based on completing services on several Healthcare Effectiveness Data and Information Set (HEDIS^®) measures. Assigned PCPs and specialists are paid extra for closing these HEDIS^® care gaps:

• Adult access to primary care (AAP)
• Blood pressure control (CBP)
• Blood pressure control for diabetics (BPD)
• Breast cancer screening (BCS)
• Hemoglobin A1c<8 (HBD)
• Follow up after emergency department visit for mental illness or substance abuse by any provider type (FUM and FUA)
• Prenatal and postpartum care for members with live births from October 8, 2023, to October 7, 2024 (PPC)
• Cervical cancer screening (CCS)
• Adolescent immunizations (combo 2) (IMA)
• Childhood immunizations by age 2 (combo 10) (CIS CO10)
• Well-child visits 0-14 months (6 or more visits within first 15 months) and well-child visits 15-30 months (2+ visits) (W30)
• Well-child visits ages 3-21 (WCV)
• Follow-up after hospitalization for mental illness services rendered by licensed behavioral health providers (FUH)

Every Medicaid recipient is required to have an assigned PCP. The previous minimum program eligibility requirement to see 50% of member panel has been retired. In 2024, participating providers with a member panel of 100 or more are eligible. 

For 2024, the measurement year is January 1, 2024, to December 31, 2024. We’ll share visit performance data with providers throughout the year.

2024 Pay-for-Performance measures, targets and payments (PDF)

Providers will receive financial incentives for completing services on several HEDIS^® measures. For 2024, there are two methods of payment: a three tiers method and an annual flat rate method.

Tiers:

• Reaching the 33rd percentile
• Reaching the 50th percentile
• Reaching or exceeding the 75th percentile

Annual flat rate:

For measures with an annual flat rate payment, the provider will earn the respective incentive payment for each eligible member who received appropriate treatment. 

Providers receive incentives for all gaps closed when the next performance tier is reached, or annually as indicated on the Pay-for-Performance payment table. Reconciliation occurs at the next payment cycle for any performance decline that may occur due to measure definitions.

Use reports in the Availity portal to track your progress. Your PR rep can assist with registration.

Provider P4P Program Partnership Program - Partnership bonuses

Health Risk Survey (HRS) completion

• Providers will receive $25 for every HRS completed for a new member in the first 60 days
• Providers also still have the ability to receive $10 per HRS completed for all other members

Data exchange

• Providers with more than a thousand members will receive a one-time $1,000 bonus for new supplemental data source (SDS) approved by September 1, 2024.

Notification of Pregnancy

• In addition to the Timeliness of Prenatal Care measure performance, providers can earn $30 per notification of pregnancy. Get the NOP form here.

Assess and enter Z-code (Z59.x) for problems related to housing and economic circumstances

• Providers will receive an additional $25 per member per day for entry of Z-code (Z59.x) for problems related to housing and economic circumstances.

We now provide monthly quality care gaps reports in Availity. These reports — with a detailed billing view — show our members assigned to your care with open care gaps. You can use this data to identify claims that need additional coding and members for outreach. You’ll also see your potential pay-for-performance (P4P) earnings from closing the care gaps.

Learn more here (PDF)

We've developed tip sheets to inform providers, clinical teams and billing staff about each measure found on the care gaps reports. Get 2023 tips sheets for the report measures.