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The transition from per-visit PPS toward APMs, capitation, and risk — the programs, payment models, deadlines, case studies, and the resources and courses that help your team make the shift.
8 programs · 33 resources & courses · 24 glossary terms · Updated: May 23, 2026
5
transition stages
33
resources & courses
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active programs
Three consequential VBC deadlines land on the same day: ACO REACH sunsets, the CalAIM 1115 + 1915(b) waivers expire, and the current Medi-Cal MCO tax expires. The single most important date on the FQHC VBC calendar.
Five stages from per-visit PPS to full risk, mapped to HCP-LAN APM Framework categories. Select where your center is to see what to build, what to do first, and which resources to use.
Build the foundation and the will
Still paid per-visit, but starting to ask what it would take to get paid for outcomes. The work here is foundational: clean data, an empaneled patient population, PCMH-level care, and leadership that wants to move.
NACHC
3 domains (Infrastructure, Care Delivery, People) → 15 change areas, each scored on a 1 (Learning) to 5 (Expert) maturity scale.
Health Care Payment Learning & Action Network
Category 1 (FFS, no quality link) → 2 (FFS linked to quality) → 3 (APMs on FFS: 3A shared savings, 3B downside risk) → 4 (population-based/capitated: 4A-4C).
Community Care Cooperative
7 Integrated Primary Care domains (engaged leadership, QI, access, BH integration, SUD, SDOH, trauma-informed care) + 3 supporting domains (IT, population health, finance).
Health Management Associates
6 domains: outcomes measurement, board/leadership, data/technology, partnerships, payer engagement, financial alignment.
Start with our free interactive course, then go deeper with the best FQHC-specific guides, learning collaboratives, and certificates — every one primary-sourced.
Our own interactive course: 4 modules taking you from PPS fundamentals through California's FQHC APM, the federal model landscape, and how to assess your center's readiness to take on risk. Bilingual, free, no registration.
Self-paced interactive, ~40 min · FQHC leaders, finance, QI, care teams
NACHC's free national learning community built on the Value Transformation Framework (3 domains, 15 change areas). Monthly live forums, 3 pathways (team/org, individual, grab-and-go), and a self-assessment tool. Over half of US health centers are enrolled.
CHCF's free hub for understanding CalAIM — readiness and planning resources, ECM and Community Supports explainers, and guidance on how to get involved.
A free, step-by-step guide to preparing for and operating under the California FQHC APM: care redesign, staffing, competencies, and priorities. The single best starting point for centers considering the APM.
A free self-scoring tool across the 15 VTF change areas (1 = learning → 5 = expert) to benchmark where your center stands and guide transformation priorities.
Free step-by-step playbooks on population health management, models of care, evidence-based care, and FQHC reimbursement quick tips.
Plain-language explainers on PPS, the wrap payment, APMs, and value-based payment fundamentals — ideal for onboarding new staff and board members.
Technical assistance and readiness support for California health centers preparing for or operating under the FQHC APM.
Oral-health value-based care resources, the Dental Dashboard for quality improvement, and on-demand CE courses for FQHC dental teams.
A free issue brief on improving ECM and Community Supports reimbursement by fixing billing processes — practical revenue guidance for CA FQHC finance teams.
Resources, training, and a peer community specifically for community health centers entering value-based care, launched 2025 by the largest FQHC-serving ACO enabler.
A CAHME-award-winning self-paced online certificate teaching population health management through value-based care, with continuing-education credit.
An online course covering value-based care fundamentals and population health, free to audit (paid certificate optional).
Current (May 2025) guide to FQHC payment streams — how to layer professional services, care-management codes, and APMs on top of PPS.
A scaled self-assessment of the competencies an FQHC needs to participate in payment-reform models — the FQHC-specific complement to the VTF assessment.
A financial-readiness and revenue-projection model for FQHCs to test value-based payment and capitation scenarios.
How to structure, staff, and bill a care-management program to meet CMS reimbursement requirements — the engine of VBC performance.
The standardized SDOH risk-assessment tool (25+ languages; ICD-10/LOINC/SNOMED coded) plus a full toolkit for screening and responding to social needs.
How FQHCs bill the new Medicare Advanced Primary Care Management codes (G0556/G0557/G0558) — a key bridge revenue stream into VBC.
Health-IT-focused VBP readiness resources for health centers, including the hosted payment-reform readiness tool.
Profiles four real FQHC value-based payment models (Oregon APCM, Washington APM4, Illinois Medical Home Network, Minnesota FUHN).
A free self-assessment gauging readiness across six domains: outcomes measurement, board/leadership, data/tech, partnerships, payer engagement, and financial alignment.
A maturity-leveled readiness assessment for risk-bearing provider organizations (ACOs, IPAs, clinically integrated networks).
Statewide technical assistance preparing California FQHCs for capitation/APM — site visits, convenings, and coaching.
California's operating capitation-readiness cohort (Comprehensive + Low-Intensity tracks) for FQHC teams making the APM transition.
An FQHC-governed ACO that publishes its Integrated Primary Care VBC journey and a 10-domain capitation-readiness model adapted from NACHC's tool.
A health-value and population-health-management certificate (core courses include Population Health Management Approaches and Community-Engaged Health Improvement).
The full 7-course Coursera specialization on value-based care, with a capstone — the in-depth path beyond the single population-health course.
A two-module finance credential covering the business of health care and operational excellence, including value-based payment models.
The HCC / risk-adjustment coding credential — the documentation-accuracy skill that drives the benchmarks VBC contracts are measured against.
Weekly interviews with value-based care executives and clinicians, with a strong primary-care-transformation catalog.
A physician-led ACO planning guide with model profiles and a calculator to estimate revenue across CMS tracks.
Up-front capital for new low-revenue, rural, or underserved ACOs to fund staffing, infrastructure, and SDOH — a key way to finance the VBC transition.
California's voluntary program letting FQHCs swap PPS per-visit billing for a capitated PMPM equal to their total projected PPS payment entitlement, paid through Managed Care Plans. The goal: free centers from the per-visit treadmill to redesign care (telehealth, group visits, team-based and asynchronous touches). New cohorts onboard each January 1; applications are due roughly 12 months ahead (~Dec 16).
Why it matters for FQHCs
The single most important VBC vehicle for California FQHCs. Guardrails: participating centers must maintain ≥70% of historical PPS-eligible visit utilization, and a PPS reconciliation safeguard pays the difference if PMPM payments fall short — a downside-protected floor that makes the leap safer than most APMs.
California's Medicaid transformation. ECM provides comprehensive, whole-person care management to high-need members; Community Supports fund non-clinical services (housing navigation, medically tailored meals, sobering centers) as cost-effective substitutes for higher-acuity care. Both run through Managed Care Plans and are core to the FQHC value-based revenue mix.
Why it matters for FQHCs
ECM ($956M total funds, FY25-26) and Community Supports ($231M) are major FQHC revenue lines. The 1115 waiver expires Dec 31, 2026 — but DHCS intends to continue ECM via existing managed-care authority, so ECM is more insulated from the cliff than Community Supports (which depend on waiver renewal).
CMS's permanent Medicare ACO program. BASIC track offers a glide path (including upside-only levels) toward the two-sided ENHANCED track. The most common on-ramp for FQHCs into Medicare value-based care, usually via enablers like Aledade.
Why it matters for FQHCs
The safest first step into Medicare risk. Note: the CY2026 final rule shortens the BASIC upside-only window from 7 to 5 years (agreements starting Jan 1, 2027) and removes the health equity adjustment from the quality score — pushing FQHCs toward downside risk sooner.
Total-cost-of-care ACO model for Traditional Medicare with two risk tracks (Professional 50% / Global 100%) and primary-care capitation options. Performance Year 2026 is the final year — the model ends December 31, 2026.
Why it matters for FQHCs
Heavy safety-net participation: 1,042 FQHCs/RHCs/CAHs in 2024 (>25% increase over 2023). Its sunset, with the LEAD successor not starting until Jan 2027, creates a potential gap-year disruption for participating centers. CMS also renamed the 'Health Equity Benchmark Adjustment' to a budget-neutral 'population adjustment.'
The official successor to ACO REACH and the longest performance period CMMI has ever set: a 10-year run (Jan 1, 2027 → Dec 31, 2036) with benchmarks set initially and held over the decade rather than periodically rebased. Focus on dual-eligible coordination and episode-based specialist risk.
Why it matters for FQHCs
Includes an explicit add-on payment for rural providers to build ACO infrastructure, plus a dual-eligible (Medicare+Medicaid) focus — both directly relevant to safety-net providers. This is where REACH-participating FQHCs are expected to migrate. Applications expected during 2026.
A CMMI model testing prospective, population-based primary care payments within MSSP. Participants get a one-time $250,000 Advanced Shared Savings Payment plus monthly Prospective Primary Care Payments (PPCP) that replace fee-for-service for primary care.
Why it matters for FQHCs
Includes an explicit FQHC/RHC PPCP enhancement — ACOs with a higher proportion of FQHCs/RHCs see MORE net revenue. Directly advantages FQHC-heavy ACOs. Monitor for early changes given the CMMI strategy refresh.
A 10.5-year multi-payer advanced primary care model across 8 states and the first CMMI model to include FQHCs in a multi-state advanced primary care test (FQHCs got upside-only risk). Terminated early on December 31, 2025 as part of CMMI's March 2025 termination wave.
Why it matters for FQHCs
Was a major FQHC on-ramp into advanced primary care; its early termination is a notable loss for participating health centers and a signal of the new 'fewer, more rigorous models' direction.
A voluntary advanced primary care payment model (population-based payment plus a flat visit fee and a performance-based adjustment). Ended early December 31, 2025, a year ahead of its scheduled close.
Why it matters for FQHCs
One of four models CMMI terminated early in 2025 (~$750M projected savings). Its closure narrows the menu of advanced primary care options available to FQHCs entering Medicare VBC.
The traditional FQHC method: a fixed, all-inclusive per-visit rate per Medicaid/Medicare encounter, set per center and inflation-adjusted by the Medicare Economic Index.
For FQHCs: The baseline that VBC moves away from. It rewards visit volume and pays nothing for phone, text, group, or asynchronous care — the very modalities that improve access for working patients.
A fixed per-member-per-month (PMPM) payment for an assigned panel regardless of visit count. California's FQHC APM sets the PMPM equal to a center's projected PPS entitlement, with a PPS-equivalent floor and a ≥70% utilization rule.
For FQHCs: Frees care teams to redesign how they reach patients — telehealth, group visits, CHW outreach, async messaging — without losing revenue. The CA APM's reconciliation floor makes it the lowest-risk capitation entry available to FQHCs.
An ACO keeps a share of the savings it generates versus a spending benchmark, with no penalty if it overspends.
For FQHCs: The safe on-ramp into Medicare value-based care — most FQHCs start here (MSSP BASIC lower levels). It builds the data and care-management muscle needed before taking on downside risk.
An ACO shares in savings AND must repay losses if spending exceeds the benchmark. Higher reward, real financial exposure.
For FQHCs: Requires reserves or reinsurance to absorb potential losses. CMMI's new strategy is pushing all participants toward this — under-capitalized FQHCs should secure downside protection (stop-loss, enabler partnerships) before entering.
A new (2025) Medicare monthly per-patient care-management payment — not a full APM, but value-oriented. Three tiers by patient complexity: G0556 ($15.20), G0557 ($48.84), G0558 ($107.07, for Qualified Medicare Beneficiaries).
For FQHCs: Directly billable by FQHCs/RHCs. As of July 1, 2025 centers stop using G0511 and bill the APCM codes — a concrete new monthly revenue stream for care management that requires no downside risk.
Partial risk covers a slice of spending (e.g., the primary care budget); full/global risk covers the total cost of care across all services. The deepest end of the VBC pool.
For FQHCs: Most FQHC value-based care is partial risk. Full risk is the domain of mature operators — AltaMed, for example, takes global risk on its PACE program. Full risk demands sophisticated actuarial, utilization-management, and reserve capabilities.
First cohorts of FQHCs begin capitated PMPM payments in place of PPS per-visit billing.
FQHCs/RHCs stop billing G0511 and begin billing the new Advanced Primary Care Management codes (G0556/G0557/G0558).
CMMI ends four value-based models early as part of its March 2025 strategy refresh — including the two major advanced primary care on-ramps for FQHCs (MCP and PCF).
The new CMS-HCC risk-adjustment model reaches full phase-in, cutting average MA risk scores ~3.12% (~$11B savings) and raising documentation specificity demands on risk-bearing providers.
DHCS public comment period (Feb 10 – Mar 12, 2026) on the CalAIM 1115 demonstration renewal concept paper.
California's statewide health care cost-growth target becomes enforceable with the 2026 performance year (3.5%), data collected 2027, public reporting 2028.
Three consequential VBC deadlines land on the same day: ACO REACH ends, the CalAIM 1115 + 1915(b) waivers expire, and the current Medi-Cal MCO tax expires. The single most important date on the FQHC VBC calendar.
ACO REACH's 10-year successor begins, the CalAIM renewal period starts, and a new (smaller) MCO tax takes effect if federally approved.
The prospective primary care payment model with its FQHC/RHC enhancement reaches its scheduled close.
California's target to raise primary care to 15% of total medical expense statewide (from as little as ~7% today) — a structural tailwind for FQHCs.
Aledade, the largest network of independent primary care in value-based care, runs MSSP ACOs including community-health-center-only ACOs and partners with FQHCs/RHCs. It includes more than 25% of all community health centers participating in MSSP.
The largest independent FQHC network in the US (60+ centers across LA and Orange County, 700,000+ patients/yr, ~465,000 Medi-Cal patients) operates an IPA plus health-plan partnerships and takes global risk on its PACE program (since 1996). It is running a Medicare risk pilot on roughly 2,000 of ~18,000 attributed Medicare lives.
A peer-reviewed study (Journal for Healthcare Quality, 2022) compared health centers applying NACHC's Value Transformation Framework against nonparticipating centers nationally over three years.
A December 2024 Penn LDI analysis frames value-based payment as still 'a teacup in a roaring sea' of FQHC revenue: centers juggle 10–15 funding streams, 70%+ report physician/nurse shortages, and 77% report mental-health provider shortages. Yet FQHCs regularly meet or exceed national benchmarks for hypertension and diabetes control.
New Medicare monthly per-patient care-management payment billable by FQHCs/RHCs (codes G0556/G0557/G0558). Effective Jan 1, 2025; FQHCs stopped using G0511 and began billing the new codes July 1, 2025.
Effective July 1, 2025 for FQHCs/RHCs
Shortens the BASIC track upside-only window from 7 to 5 years (agreements starting Jan 1, 2027), removes the health equity adjustment from the quality score (PY2026), removes the SDOH screening measure, and adds a cyberattack EUC exception.
Finalized October 31, 2025
The new Medicare Advantage risk-adjustment model phases in to 100% for payment year 2026, cutting average risk scores ~3.12% (~$11B savings) and demanding more documentation specificity from risk-bearing providers.
Fully phased in PY2026
California's statewide cost-growth target (3.5% for 2025-26, stepping to 3.0% by 2029) plus a primary-care investment benchmark targeting 15% of total medical expense by 2034 (from ~7% today). Enforcement begins with the 2026 target.
Benchmark board-approved Oct 2024; enforcement begins 2026
The current Medi-Cal MCO tax expires end of 2026. The 2026-27 May Revision proposes a new (smaller) MCO tax effective Jan 1, 2027 — constrained by H.R. 1 and Prop 35 — to fund Medi-Cal provider rate increases that underpin VBC economics. Needs federal approval.
Proposed in 2026-27 May Revision
Would direct CMS to create hybrid primary-care payments (PMPM at 40–70% of expected FFS charges) and cut beneficiary cost-sharing 50%. Introduced and referred to Senate Finance in the 118th Congress; re-introduction in the current Congress is unconfirmed.
Referred to Senate Finance (118th Congress)
Making Care Primary (FQHCs' first multi-state advanced primary care model) and Primary Care First were killed Dec 31, 2025. Four models terminated, one reduced, two canceled — narrowing the menu of safe FQHC entry points.
ACO REACH (1,042 FQHCs/RHCs/CAHs in 2024) ends Dec 2026, but the LEAD successor doesn't start until Jan 2027 — a possible disruption for centers mid-transition.
CMMI's new strategy prioritizes provider-borne downside risk and signals more mandatory models. Under-capitalized FQHCs could be pushed into risk they cannot absorb.
MSSP removes the health equity adjustment from the quality score (PY2026) and drops the SDOH screening measure; ACO REACH renamed its equity adjustment to a budget-neutral 'population adjustment' — fewer protections for safety-net providers.
The CalAIM 1115 waiver expires Dec 31, 2026. Community Supports especially depend on waiver renewal (not guaranteed); ECM is partly insulated via managed-care authority.
'A teacup in a roaring sea' — FQHCs juggle 10–15 funding streams amid workforce shortages (70%+ MD/RN, 77% behavioral health) and stagnant, non-inflation-updated PPS rates, limiting the bandwidth to invest in VBC transformation.
The vocabulary of the transition — every definition with its primary source.
The Medicaid FQHC payment method: a fixed per-visit (per-encounter) rate based on a center's historical costs, trended annually by the Medicare Economic Index.
CMSA supplemental payment a state makes to reconcile what a managed care plan pays an FQHC up to the center's full PPS per-visit entitlement.
MACPACA fixed payment per member per month for a defined set of services regardless of utilization, shifting financial risk to the provider.
DHCSA payment approach that ties payment to value/outcomes rather than straight fee-for-service; California's FQHC APM pays a clinic-specific PMPM equal to projected PPS.
DHCSPayment that holds providers accountable for the quality and total cost of care rather than the volume of services.
NACHCA group of providers who voluntarily join to coordinate care for a defined population and share accountability for its quality and cost.
CMSMedicare's permanent ACO program; ACOs that beat a spending benchmark while meeting quality standards share in the savings (and, in two-sided tracks, the losses).
CMSA CMS Innovation Center capitated/risk-bearing ACO model with a health-equity focus — ending Dec 31, 2026 and succeeded by the LEAD Model (2027).
CMS Innovation CenterAn arrangement where the provider shares in savings but must also repay the payer a portion of spending above the benchmark.
AledadeAn arrangement where the provider shares in savings if it beats the benchmark but owes nothing if spending runs over.
AledadeThe full cost of all care for an attributed population over a period; accountability for TCOC increases as models move toward HCP-LAN Category 4.
HCP-LANThe method that assigns each patient to a provider or ACO (e.g., by where they get most primary care) so that population's cost and quality count for that provider.
CMSThe target spending amount an ACO is measured against; spending below it (with quality met) generates shared savings, above it can generate losses.
CMSCMS's Hierarchical Condition Category model that adjusts benchmarks for how sick a population is, producing a Risk Adjustment Factor (RAF) where 1.0 is average.
HHS OIGThe 2024 CMS-HCC risk-adjustment model (fully phased in for 2026), which remapped ICD-10 codes, raised the HCC count from 86 to 115, and lowered RAF for many conditions.
HHS OIGA monthly, population-based payment for primary care that replaces fee-for-service for those services (used in ACO Primary Care Flex).
CMS Innovation CenterA 2025 Medicare monthly care-management benefit (codes G0556/G0557/G0558, tiered by complexity) that FQHCs and RHCs can bill; requires 13 service elements.
CMSCalifornia Medi-Cal's whole-person, community-based care-management benefit for the highest-need managed-care members — 7 core service components, billed PMPM through plans.
DHCSCalifornia Medi-Cal's menu of 15 pre-approved services (Transitional Rent mandatory as of Jan 1, 2026) that plans may offer as cost-effective substitutes for higher-cost care.
DHCSCalifornia Advancing and Innovating Medi-Cal — DHCS's multi-year initiative of delivery-system, program, and payment reforms, including ECM and Community Supports.
DHCSCalifornia's target requiring payers to raise primary care spending to 15% of total medical expense by 2034 (≈0.5-1.0 percentage points per year).
HCAIA four-category taxonomy: Cat 1 = FFS (no quality link); Cat 2 = FFS linked to quality; Cat 3 = APMs on FFS (3A shared savings, 3B downside risk); Cat 4 = population-based/prospective.
HCP-LANHRSA's standardized annual reporting set for FQHCs, including clinical quality measures (e.g., blood-pressure control, diabetes HbA1c) aligned with HEDIS.
HRSANCQA's Healthcare Effectiveness Data and Information Set — the health-plan performance measure set (90+ measures) used by 90%+ of U.S. plans and often anchoring VBC contracts.
NCQA