Participant Providers Frequently Asked Questions
Q: What patients (beneficiaries) are eligible for alignment to a Direct Contracting Entity (DCE) under CMMI’s Direct Contracting model?
A: Beneficiaries will be eligible for alignment to a DCE if they meet the following criteria:
- Are enrolled in both Medicare Parts A and B
- Are not enrolled in an Medicare Advantage plan, Medicare Cost Plan under section 1876, PACE organization, or other Medicare health plan;
- Have Medicare as their primary payer;
- Are a resident of the United States; and
- Reside in a county included in the CHP service area.
Q: How are my patients attributed to a DCE?
A: Beneficiaries (eligible patients) may be aligned to a DCE in two ways:
- Voluntary alignment, where beneficiaries communicate their desire to be aligned with a DC Participant Provider, which is a provider who has contracted with the DCE to participate in the model. Voluntary alignment can be completed by a beneficiary either by selecting a “primary clinician” on MyMedicare.gov or, completing a paper-based form using a template developed by CMS (the “Voluntary Alignment Form”).
- Claims-based alignment, where beneficiaries are aligned based on where the beneficiary has historically received the plurality of their primary care services, as evidenced in claims utilization data.
Q: How am I compensated by the Clover Health Partners (CHP)? Do I still submit claims to CMS?
A: CHP Participant Providers continue to submit claims to CMS and are compensated in two ways by CHP:
- CHP Participant Providers receive 100% of the Medicare Allowable Rate for the Covered Services provided to Beneficiaries by Participant.
- CHP Participant Providers receive a $45 Clover Assistant payment within 7 days of submitting a Clover Assistant visit (in-person, video telehealth or audio only telehealth).
Q: Is the Direct Contracting model an Advanced Alternative Payment Model (APM)?
A: The Direct Contracting model is considered a Merit-based Incentive Payment System (MIPS) APM under the definition at 42 C.F.R. 414.1305. Direct Contracting will be an Advanced Alternative Payment Model (APM) starting in the first performance year (PY1), which will be 2021. Eligible clinicians who are participants in the model and meet the definition of Affiliated Practitioner in 42 C.F.R. 414.1305 will be eligible for Qualifying APM Participant (QP) determinations.
Q: What quality measures will CMS use for quality reporting?
A: CMS will assess a DCE’s quality performance based on a core set of claims-based quality measures as well as information from administration of the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) for Accountable Care Organizations (ACOs) surveys. The quality strategy for the Direct Contracting model is designed to provide achievable performance criteria that incentivize practice transformations necessary to reduce utilization and improve quality of care.
Q: Can I participate in other Medicare shared savings programs, including CPC+?
A: DCE Participant Providers may not simultaneously contract with any other DCE or participate in any original Medicare fee for service initiative that involves shared savings, including CPC+.
Q: Why are my patients receiving Welcome Letters?
A: Your patients are receiving these letters because you are a Participant Provider with Clover Health Partners. The Center for Medicare and Medicaid Services (CMS) requires that we, Clover Health Partners, send this letter to all beneficiaries aligned to Clover Health Partners as of 1/1/2022.