AHEAD Model Overview

AHEAD Model Overview

States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model

Overview: CMS has approved New York’s participation in Cohort 3 of the AHEAD model, covering the Bronx, Kings, Queens, Richmond, and Westchester counties. This model supports a shift to global budgets for hospitals while also providing funding opportunities for primary care providers.

Key Details:

  • Program Phases:
    • Pre-Implementation Phase: Begins in January 2025 and will last two years.
    • First Performance Year: Starts in January 2027 and extends through 2034.
  • Funding Model:
    • For Hospitals: The AHEAD model establishes a global budget for Medicare fee-for-service patients, with the potential for additional payer alignment over time.
    • For Primary Care Providers (including FQHCs): The Primary Care AHEAD component offers an Enhanced Primary Care Payment (EPCP) with a per-member per-month (PMPM) rate of approximately $17 for attributed Medicare patients only. Participating providers are expected to offer integrated behavioral health, enhanced care management, specialty coordination, and address Health-Related Social Needs.
    • PPS Rate and Billing Adjustments: Health centers will retain their Medicare PPS rate; however, those opting into the AHEAD model may need to zero out separate billing for certain care coordination codes.
  • Performance Requirements: Participating primary care providers must meet specific quality standards. Failure to meet these standards may result in a reduced PMPM rate or, in some cases, exclusion from the program.
  • Medicaid Alignment: Discussions between CHCANYS and DOH confirm that Medicaid alignment under this model will solely consist of the already approved PCMH increase from $6 to $8 per member per month. This is not a new increase; it was previously approved in the budget and is pending CMS approval. 

Additional Resources on the AHEAD Model’s Primary Care Focus:

Please note that the pre-implementation phase will last two years, during which CHCANYS will provide ongoing information and support to help health centers understand the model and make informed decisions about participation.