PCMH Overview

Overview

PCMH is entirely voluntary and providers who participate can earn meaningful reimbursement increases of three types:

12 percentage point increase added to current fee schedule
New fees for developing care plans for select patients with certain chronic or multiple conditions that put them at risk and for monitoring progress against those plans
Additional fee schedule increases (up to an 80 point increase) based on providers' engagement with their patients, the quality of care delivered to their entire cohort of patients, and actual aggregate costs of care compared to expected costs.

The PCMH program has a significant "upside" for the provider, for the patient and for CareFirst as a steward of its members' health care dollars.

Who is Eligible?

Providers who are credentialed and in good standing in all CareFirst and CareFirst BlueChoice networks and practice in the following Primary Care specialties are eligible for PCMH:

Family Practice
General Practice
Geriatrics
Internal Medicine
Nurse Practitioners*
Osteopathy
Pediatrics

* Nurse practitioners (NP) must be certified by their relevant approved National Certification Board and meet all licensing/certification guidelines of the state in which the NP practices. NPs must also file an attestation that they have a written collaborative agreement with a physician of the same specialty who is in good standing in the same CareFirst provider networks.

Want More Information?

We urge you to read the full PCMH Program Description and Guidelines document for more information. (Viewing and printing this document requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site. To navigate the contents of the Program Description and Guidelines, read our "tips".)

Take advantage of the PCMH-specific training opportunities available through the Learning and Engagement Center.