2025 Provider Incentive Program
| Date: | January 08, 2025 |
| From: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) |
| To: | Health Plan Providers |
| Type: | Informational |
| Subject: | 2025 Provider Incentive Program |
| Business: | Medi-Cal Managed Care |
Health Plan is pleased to announce the 2025 Provider Incentive Program. This program rewards our providers for promoting quality care for our members. The incentive program will be categorized into two groups as follows:
Group A: Providers with a minimum of 40,000 Health Plan members
Group B: All other providers with a minimum of 400 Health Plan members
Program guidelines and quality measures are described in the attached document. The quality measures are derived from the Healthcare Effectiveness Data and Information Set (HEDIS) and the Managed Care Accountability Set (MCAS). MCAS are performance measures that the Department of Health Care Services (DHCS) selects for annual reporting for Medi-Cal managed care health plans. Please see the attached regarding 2025 Participation Criteria, Incentivized Quality Measures, and Program Structure.
2025 Participation Criteria
Group A
- Maintain a minimum of 40,000 Health Plan members
- Remain open to new members for the entire calendar year if your provider to member ratio is within capacity
- A minimum of 30 members in each measure denominator qualifies the measure for payout
Group B
- Maintain a minimum of 400 Health Plan members
- Remain open to new members for the entire calendar year if your provider to member ratio is within capacity
- A minimum of 30 members in each measure denominator qualifies the measure for payout
2025 Incentivized Quality Measures
Health Plan will incentivize provider performance on the following 16 target measures:
| # | Chronic Health Measures | ACRONYM |
| 1 | Controlling High Blood Pressure | CBP |
| 2 | Glycemic Status Assessment for Patients with Diabetes (>9%) | GSD |
| # | Women’s Health Measures | ACRONYM |
| 3 | Prenatal and Postpartum Care: Timeliness of Prenatal Care | PPC-Pre |
| 4 | Prenatal and Postpartum Care: Postpartum Care | PPC-Pst |
| 5 | Chlamydia Screening in Women | CHL |
| 6 | Cervical Cancer Screening | CCS-E |
| 7 | Breast Cancer Screening | BCS-E |
| # | Children’s Health Measures | ACRONYM |
| 8 | Child and Adolescent Well-Care Visits | WCV |
| 9 | Childhood Immunization Status – Combination 10 | CIS-10-E |
| 10 | Immunizations for Adolescents – Combination 2 | IMA-2-E |
| 11 | Well-Child Visits in the First 30 Months of Life – 0 to 15 Months –
Six or More Well-Child Visits |
W30-6+ |
| 12 | Well-Child Visits in the First 30 Months of Life – 15 to 30 Months –
Two or More Well-Child Visits |
W30-2+ |
| 13 | Developmental Screening in the First Three Years of Life | DEV-CH |
| 14 | Topical Fluoride for Children | TFL-CH |
| # | Behavioral Health Measures | ACRONYM |
| 15 | Follow-Up After ED Visit for Substance Use – 30 days | FUA |
| 16 | Follow-Up After ED Visit for Mental Illness – 30 days | FUM |
Program Structure
Incentive payments can be earned in the four categories below. Payment amounts cannot exceed your total incentive budget.
| Category | Incentive Amount |
| Category 1: Reaching Minimum Performance Level (MPL) on Target Measures
Incentivizes 16 measures grouped into four bundles |
Chronic Health (CBP, GSD):
· Must meet or exceed the MPL on both measures to earn 100% of the bundle budget · If only one measure meets or exceeds the MPL, you earn 60% of the budget · Can earn an additional 25% (in addition to the 60%) for reaching at least the 25th percentile on the second measure
Women’s Health (PPC-Pre, PPC-Pst, CHL, CCS-E, BCS-E): · Must meet or exceed the MPL for at least 3 of 5 measures to earn 100% of the bundle budget · If 2 measures meet or exceed the MPL, you earn 60%; if 1 measure meets or exceeds the MPL, you earn 50% of the budget
Children’s Health (WCV, CIS-10-E, IMA-2-E, W30-6+, W30-2+, DEV-CH, TFL-CH): · Must meet or exceed the MPL for at least 5 of 7 measures to earn 100% of the bundle budget · If 4 measures meet or exceed the MPL, you earn 60%; if 3 measures meet or exceed the MPL, you earn 50%; if 2 measures meet or exceed the MPL, you earn 25% of the budget
Behavioral Health (FUA, FUM): · Must meet or exceed the MPL on both measures to earn 100% of the bundle budget · If only one measure meets or exceeds the MPL, you earn 60% of the budget · Can earn an additional 25% (in addition to the 60%) for reaching at least the 25th percentile on the second measure |
| Category 2: Percentage Point Improvement
Incentivizes percentage point increase in provider’s measure rate when compared with prior year Ø Group A: Target Improvement Rate: >1% Ø Group B: Target Improvement Rate: >5% |
Points are aggregated across 13 of the 16 measures (your 3 lowest scores are excluded). The total points are calculated based on year-over-year (YoY) improvement. An increase of more than 1% or 5% from the previous year earns an incentive. Payout cannot exceed your remaining incentive budget. |
| Category 3: Bonus for Highest Cumulative Performer
If program funds remain after Category 1 & Category 2 are paid out to all providers, an additional incentive can be earned for the best performing provider from Group A and the top three best performing providers from Group B, based on the highest earned MPL percentage. |
The top provider from Group A and the top three providers from Group B can earn up to 5% of the remaining incentive program budget. Payout cannot exceed the remaining program funds.
If more than one provider from Group A or more than three providers from Group B meet this criteria, the total available funds will be divided proportionate to the membership of the providers. |
| Category 4: Bonus for Most Improvement YoY
If program funds remain after Category 3, an additional incentive can be earned for the top provider from Group A and the top three providers from Group B with the highest YoY total improvement points. |
The top provider from Group A and the top three providers from Group B that made the highest improvement from the previous year can earn up to 5% of the remaining incentive program budget. Payout cannot exceed the remaining program funds.
If more than one provider from Group A or more than three providers from Group B meet this criteria, the total available funds will be divided proportionate to the membership of the providers. |
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website www.hpsj-mvhp.org
