Mid-Atlantic Health Law TOPICS

Maryland is one of only two states, along with Vermont, launching the first cohort of the new Advancing All-Payer Health Equity Approaches and Development (AHEAD) total cost of care model which will begin next year following a planning period already underway. 

Maryland has experimented with various unique payment models for decades, most recently the Maryland Total Cost of Care Model, elements of which have been incorporated into AHEAD. 

The Centers for Medicare and Medicaid Servies (CMS) created AHEAD in an ongoing effort to develop innovative payment models that improve population health, reduce health care spending, and advance health equity by reducing disparities. AHEAD focuses on primary care investment, hospital stability and enhancing connection to community resources. 

Participating states may receive up to $12 million in the first five to six years of the program, which will run until 2034, to help cover implementation costs. States are held accountable for customized Medicare and all- payer spending growth and primary care investment targets, as well as various population health outcomes. 

Given long standing health disparities, each state will also create a Health Equity Plan (HE), with stakeholder input, that will outline opportunities for collaboration across the health care spectrum with an emphasis on community-driven strategies. 

Maryland’s AHEAD program will be governed by the Maryland Commission on Health Equity (MCHE), a multi-sector governing body that will include patients, Medicaid Agencies, Public Health Agencies, community-based organizations, payers and providers.

Hospital Participation 

Participating states will encourage hospitals to switch to a global budget model, which means that each hospital gets a fixed revenue cap set in advance based on the hospital’s specific population or services. While this will be a major shift for hospitals in some participating states, Maryland’s hospitals already operate using a global revenue framework. 

In a global budget framework, hospitals are incentivized to deliver care efficiently, seeking to reduce readmissions or shifting to outpatient or community-based services when feasible, but quality metrics help ensure sound practices remain a top priority. 

In AHEAD, hospitals may also be eligible to earn financial bonuses if performance on disparity-focused measures improves during the model.

Primary Care AHEAD 

The states will also recruit primary care providers, including small providers, hospital owned primary care providers, Federally Qualified Health Centers (FQHCs) and Rural Health Clinics, to participate in Primary Care AHEAD (PC AHEAD). There are elements of this program that are conceptually very similar to the Maryland Primary Care Program. 

Participating practices will be eligible to receive a quarterly prospective payment called an Enhanced Primary Care Payment (EPCP), which replaces some Part B care coordination and behavioral health integration codes. 

The EPCP would be in addition to the fee-for-service funds the practices traditionally receive. The per beneficiary per month rate will range from 15 to 21 dollars, depending on how well the State performs on pre-set cost savings, equity, and quality targets. The EPCP will also include an adjustment for social and medical risk of the practice’s attributed beneficiaries. Initially 5% and later 10% of the EPCP will be tied to quality performance metrics.  

EPCP funds can be used to support quality reporting and performance assessment tools, tools to develop specialty coordination, hiring staff such as care coordinators, behavioral health staff or community health workers, and targeted case management for chronic conditions. 

Each participating practice will need to incorporate several care transformation efforts, covering care coordination, meeting Health-Related Social Needs (HRSN) for patients, and integrating behavioral health support. All participating practices will conduct HRSN screenings, and will have some flexibility about what other interventions will improve the delivery of care in their individual practices.  

CMS has attempted to reduce certain burdens on primary care practices in PC AHEAD. For example, there is no minimum beneficiary count to participate in PC AHEAD. CMS has also advertised PC AHEAD as having less paperwork for providers to complete to be eligible for funds than prior payment models.

PC AHEAD plans to add additional tracks for full or partial primary care capitation in upcoming model years. 

Over the next few months, the MCHE will provide additional details about the AHEAD program and how primary care practices can join before the model begins in January 2026.
 

Alexandria K. Montanio
410-576-4278 • amontanio@gfrlaw.com