Agency MPIP Model 2024-2025

Agency MPIP Model 2024-2025

February 1, 2025- September 30, 2025

Due to the transition to the new Statewide Medicaid Managed Care (SMMC) health plan contracts on February 1, 2025, the 2023-2024 MPIP year was extended through January 31, 2025.  The MPIP Year 2024-2025 begins on February 1, 2025, with the rollout of the new contracts.

Physicians qualified to participate in the MMA Physician Incentive Program (MPIP) are the physician types listed below who meet the access and quality criteria listed below. 

MPIP Covered Physician Types:

• Pediatric Primary Care Physicians (including General Practitioners and Family Practitioners)
• OB/GYNs
• Specialist Physicians for all services provided to enrollees under the age of twenty-one (21) years.
  • Plans must reimburse both in and out-of-network Emergency Room physicians at the MPIP enhanced rates for services rendered to members under 21 years of age.
  • Plans must reimburse all out-of-network Hospital-based Specialty physicians at the MPIP enhanced rates for services rendered to members under 21 years of age.

2024 – 2025 MPIP - Qualified Providers:

Below is a list of Primary Care Physicians and OB/GYNs by name, reported by the plans to the Agency, who meet the 2024-2025 Agency MPIP qualifying criteria prior to the implementation date. All specialist physicians serving members under the age of 21 qualify for the MPIP program and will not be listed on the Qualified Providers list. Specialists are encouraged to work with their respective health plans to submit claims for the MPIP enhanced rates when providing services to members under the age of 21. Qualified providers will begin to receive enhanced rates for dates of service beginning on or after the implementation date.

During 2024 -2025 MPIP, plans are required to reassess Primary Care and OB/GYN physician eligibility for enhanced rates for dates of service beginning on or after May 1, 2025. This allows providers who become qualified after the February 1, 2025, implementation date a second opportunity to become eligible for MPIP. The 2024 - 2025 MPIP qualified provider list, available at the link below, will be updated after each reassessment. 

2024 -2025 MPIP Qualified Providers List: February 1 , 2025 – September 30, 2025 [ 42.5 MB ]

Note: The February and May MPIP qualification windows do not apply to determining MPIP eligibility for specialty physicians. Therefore, there should not be a delay in specialty physicians receiving enhanced payments, even if they joined a plan network between February and May.

If you are a provider contracted with a health plan to provide services and you feel that your name was omitted from the Qualified Providers List in error, please contact the plan directly. Plan contact information for providers can be found at the link below.

Health Plan Contacts for Providers [ 81.7 kB ]

MPIP Qualifying Criteria:

Pediatric Primary Care Physician (PCP)

Option 1 – A site has been recognized by one of the following organizations as a Patient-Centered Medical Home (PCMH) with a recognition date on or before February 1, 2025:

National Committee for Quality Assurance (NCQA)
Accreditation Association for Ambulatory Health Care (AAAHC)
The Joint Commission (TJC)
Utilization Review Accreditation Commission (URAC) 

Option 2 – A site with at least fifty (50) panel members must achieve or exceed the benchmarks for the following metrics. All measures below must be calculated using HEDIS Measurement Year 2023 specifications/Child Core Set specifications for Measurement Year 2023 services.

Obstetrician/Gynecologist (OB/GYN)

Option 1 - A site has been recognized as a Patient Centered Specialty Practice (PCSP) by the National Committee for Quality Assurance (NCQA) or by one of the following organizations as a Patient-Centered Medical Home (PCMH) with a recognition date on or before February 1, 2025:

National Committee for Quality Assurance (NCQA)
Accreditation Association for Ambulatory Health Care (AAAHC)
The Joint Commission (TJC)
Utilization Review Accreditation Commission (URAC)

Option 2 – Site must achieve or exceed the benchmark for all three of the following measures for the health plan’s Medicaid members. 

Specialty Physicians

All physicians who are Specialists, regardless of board certification. No additional qualification measures are required.
Additional information on types of physicians excluded from the MMA Physician Incentive Program is available on the Excluded Providers page.

2024-2025 MPIP - Included Services and Enhanced Payments:

Pediatric Primary Care Physicians and Obstetricians/Gynecologists

The included services to qualify for enhanced payments for Pediatric Primary Care Physicians and Obstetricians/Gynecologists are the following:
- All services provided to recipients under the age of 21 years by a qualified primary care physician
- All OB/GYN services rendered to pregnant women.

Specialty Physicians

Included services are all medically necessary specialist services provided to recipients under the age of 21 years.

Enhanced Payments

Payment to a qualified provider for included services will be equivalent to the Medicare Specific Locality fee-for-service rate that is in effect as of January 1, 2025 (for services provided February 1, 2025 – September 30, 2025) when a Medicare rate is available for the code associated with the included service. Payments to qualified providers may be made either through a capitated arrangement or on a fee-for-service arrangement, as defined by the health plan.
NOTE – The enhanced rates for included services are calculated by health plans, according to Medicare rates, effective February 1, 2025.

Legislative Increase for Pediatric Care

The General Appropriations Act for Fiscal Year 2023-2024 (SB 2500) included an appropriation to increase reimbursement rates for physicians providing pediatric care, including those physicians providing pediatric care currently being paid at the Medicare rate to amounts greater than Medicare reimbursement rates. In accordance with this act, effective October 1, 2024, the reimbursement rates for qualifying physicians for services rendered to members under 21 years of age during the 2024-2025 rate year shall be made at 106.2% of the Medicare or Medicare equivalent rates outlined below.

Pediatric Evaluation and Management Code Enhanced Payments

For pediatric evaluation and management codes included in the file at the following link, the 2025 MPIP Rates for Children’s Primary Care Codes will be used for enhanced payments for services provided between February 1, 2025 – September 30, 2025. The reimbursement rates listed in this file reflect an increase to 106.2% of the Medicare rate for this time period.

MPIP Rates for Children’s Primary Care Codes [   20.8 kB ]

The 2025 file will be posted when available and communicated to the SMMC plans.

Other Enhanced Payments

For codes without rates published on First Coast’s website but that have Medicare Relative Value Units (RVUs), the rate calculation methodology below (as published by the Centers for Medicare & Medicaid Services at   https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html) must be used. 

For MPIP included service codes that do not have a Medicare equivalent and for which RVUs = 0, the managed care plan must use the following formula:

Florida Medicaid rate x 1.6667 = Medicare equivalent rate*

*This Medicare equivalent rate must be reduced by the 2% sequestration.

Additional Program Documents

• Florida Medicaid Cesarean Rate Calculation [ 65 kB ]
• Florida Managed Medical Assistance Physician Incentive Program (MPIP) Rate Calculation Guidance [ 57.1 kB ]