Mid-Atlantic Health Law TOPICS

In November 2025, the State of Maryland and the Centers for Medicare and Medicaid Services (CMS) amended the Achieving Healthcare Efficiency through Accountable Design (AHEAD) model agreement. Most of AHEAD pertains to hospital rates, but part of AHEAD also impacts Medicare payments to primary care providers. Accordingly, the Maryland Department of Health (MDH) has announced some major updates to the AHEAD Primary Care Programs. 

Maryland’s AHEAD Primary Care Program now comprises four distinct paths. The Infrastructure Path, known as EQIP Primary Care (EQIP-PC), began in January 2025 and is geared towards building new primary care practices. The Medicaid Path (Medicaid Advanced Primary Care Program) came online in August 2025.

Finally, the Medicare Path which encompasses two distinct programs: Primary Care AHEAD (PC AHEAD) which began in January 2026; and Maryland Primary Care AHEAD (MDPCP AHEAD), which is conceptually similar to MDPCP and will continue through 2028, when CMS and the State will determine whether to extend the program through 2035.

Although enrollment for the Medicaid Path has closed for 2026, there may be additional enrollment opportunities for 2027 and beyond.
There will be a new enrollment opportunity for practices who want to join either MDPCP or PC AHEAD in 2027, details of which will be shared by CMS during calendar year 2026. However, participation in the Medicaid Path is a prerequisite to participate in PC AHEAD as of 2026, and will be a prerequisite for MDPCP AHEAD beginning in 2027.

All programs will continue to pay fee-for-service (FFS) to primary care practices. In addition, PC AHEAD, MDPCP AHEAD, and the Medicaid Path feature both claims-based and non-claims-based payments, including Care Management Fees and quality payments or adjustments. MDPCP also has an expanded Health Equity Advancement and Resource Transformation (HEART) payment for qualifying beneficiaries.

A. Medicaid Advanced Primary Care Program

Updates to the Medicaid Path include an increase to the FFS rates for evaluation and management (E&M) codes paid to primary care providers, who now receive 103% of Medicare FFS rates.

Participating practices will also receive Care Management Fees (CMF) of $2 per member per month, which is not at risk, and paid prospectively on a quarterly basis directly from the Managed Care Organizations (MCOs) with whom the practice contracts under the Medicaid Path.

Participating practices receiving CMF are subject to Care Transformation Requirements (CTRs) as well as Chesapeake Regional Infor-mation Reporting System for Patients (CRISP) requirements. Further details on both sets of requirements are available in the Provider Manual.
Participating practices may also receive quality incentives for which measurements began in calendar year 2026, with quality payments beginning in CY 2027.

The Medicaid Path will encompass two quality incentive payment arrangements. Pay-for-performance (P4P) and Pay-for-reporting (P4R). 
P4P is claims-based and does not require reporting. MDH will provide incentives for performance on four specific claims-based measures in the areas of health care utilization and primary care access and preventive care. 

Under P4R, participating practices will have to report measures via CRISP in the areas of behavioral health, chronic conditions, and prevention and wellness.  

B. Medicare Path: PC AHEAD

The PC AHEAD program has expanded to four pathways with increasing payments and risk: Basic, beginning in 2026, Advanced (2027), Partial Capitation (2029), and Full Capitation (2029).

Practices must choose between participating in PC AHEAD or participating in MDPCP AHEAD; a practice may not participate in both programs.
PC AHEAD is likely a better fit for practices that are newer to value-based payment arrangements, but participants in this path may realize comparatively lower program-related revenue as compared to MDPCP AHEAD.

PC AHEAD participants receive a prospective Enhanced Primary Care Payment (EPCP) at the beginning of each quarter for each attributed beneficiary. Partially capitated payments consist of an EPCP, a partially capitated prospective quarterly payment per-beneficiary per-month (PBPM), and a reduced FFS payment at 50% of billed claims for select primary care and E&M codes.

Fully capitated payments include an EPCP, and a fully capitated prospective quarterly PBPM payment representing 100% of the participant’s expected Medicare FFS payments for select primary care services within the capitation scope for historically attributed beneficiaries.

PC AHEAD participants may continue FFS billing for codes that are not duplicative of the PC AHEAD EPCP.

EPCP amounts vary depending on practice-specific and beneficiary-specific adjustments and may be subject to recoupment beginning in the practice’s second implementation year (IY) based on performance on quality and utilization measures from the previous IY. Generally, however, the statewide average is presently $21 per beneficiary per month.

The quality measures for PC AHEAD include claims-based utilization measures, as well as electronic Clinical Quality Measures (eCQMs) such as colorectal cancer screening, depression screening, and comprehensive diabetes care.  PC AHEAD CTR categories include behavioral health as a function of primary care; care management and specialty coordination; and health promotion activities.  Practices will be required to report on these categories beginning in 2027.

C. Medicare Path: MDPCP AHEAD

MDPCP AHEAD is a continuation of the previous MDPCP Track 2 for attributed beneficiares. Beginning in 2026, the Comprehensive Primary Care Payment (CPCP) is calculated as a hybrid payment, of which 65% is paid per member per month prospectively each quarter in accordance with CMS’ practice specific look back period, and the remaining 35% is paid under a reduced FFS amount as the practice bills throughout the year. In calculating this payment, CMS identifies a list of select primary care service codes and applies an enhanced fee schedule which is 110% of the standard reimbursement rate for those select codes.

HEART payments can now be used for beneficiary-level expenditures for any high-need (as determined by the practice) MDPCP beneficiary. These payments will be calculated using the Community Deprivation Index (CDI) as the indicator of social need, in addition to risk tiers, to determine whether HEART payments will be issued for a particular beneficiary.

In addition, when practices sign their participation agreements, they can opt-in to benefit enhancements for telehealth visits and non-physician (NPs, PAs) care management visits. The Telehealth enhancement ensures that practices will be able to keep billing telehealth claims for MDPCP beneficiaries without regard to federal-level telehealth requirements. The non-physician enhancement allows NPs and PAs to expand their services related to care management and care plans, but this enhancement is not available to Federally Qualified Health Centers.

Michael J. Brown
410-576-4030 • mbrown@gfrlaw.com