Cohort Management

What is the Cohort Management Program?

Care Compass Network’s (CCN) Cohort Management Program is designed to support the active management of priority Medicaid population cohorts, whereby partners from networks, integrate services, and are held jointly accountable for population outcomes. This type of collaborative network is not new – there are small and large-scale networks occurring across New York State.


The goal of this formalized program is to help our partners transition to a new Value-Based Payment (VBP) model where outcomes are incentivized rather than paid as a fee-for-service.

Benefits of Joining a Cohort Program Network

  • Opportunity to develop skills necessary in a Managed Care environment
  • New network connections and relationships
  • Learn how to administer funds differently
  • Learn how to work in a new payment model

Program Requirements


What to Expect

Partners should read through the Cohort Management Program Overview located in the Toolkit drop down box for full details and instructions. For assistance, see the Contacts drop down box.


On July 13, 2018, Care Compass Network held a Cohort Management Program Kick-Off/ PAC Stakeholders meeting to introduce the Cohort Management Program. CCN discussed what the program will entail and what the process will be for partners to contract under this new program.

Cohort Launch Drill Down Tool Demo



Cohorts is a set of individuals, defined by characteristics or triggering events. A cohort may be a static group of individuals or dynamic, meaning the group members change over time.

Community Based Organization (CBO) Tier Levels

Tier 1: Non-profit, non-Medicaid billing, community based social and human services organizations (e.g. housing, social services, religious organizations, food banks, and mobility management)

Tier 2: Non-profit, Medicaid billing, non-clinical service providers (e.g. transportation and care coordination)

Tier 3: Non-profit, Medicaid billing and clinical service providers licensed by the NYS Department of Health (DOH), Office of Mental Health (OMH), Office for People with Developmental Disabilities (OPWDD), Office of Alcoholism and Substance Abuse Services (OASAS), and independently owned primary care

Other: Any organization that does not meet all characteristics of the definitions above (e.g. a for-profit organization)

Value-Based Payment is an approach that rewards quality outcomes and improved patient care, requiring providers from across the care continuum to work together to improve patient care. This is a patient-centered approach where all providers work together to improve quality of life.

Value-Based Payment Lead Contractor (VLC) serves as the network lead for contracting with CCN. The VLC is an entity that is likely to lead contract negotiations with a Managed Care Organization (MCO) on behalf of a network.

Frequently Asked Questions


Q. How many cohorts/networks does CCN expect to support?

A. It is anticipated that CCN will support approximately 20 cohorts which could be part of one or more networks.


Q. How many cohorts can a single Network manage?

A. This is entirely up to the capacity of the network, but CCN suggests networks begin with one cohort and add additional cohorts after launching the first.


Q. How does the Cohort Management Program coordinate with the Department of
Health Behavioral Health Collaborative Care (BHCC) initiative?

A. The Cohort Management Program and the BHCC are complementary. The BHCC’s are tasked with meeting metrics just as DSRIP is; however, those collaboratives were formed to work exclusively with Behavioral Health patients. Whereas, the Cohort Management Program and DSRIP in general strives to meet metrics for all patients.


Q. Can the lead entity of a BHCC serve as the Value-Based Payment Lead Contractor
(VLC) in the Cohort Management Program

A. Yes, those activities are highly aligned.


Q. How will the Cohort Management Program relate to patient management within
Health Homes, Managed Medicaid, MCOs, and PCPs?

A. The Cohort Management Program is similar to the Health Home model, but allows inclusion based on social determinants of health in addition to clinical factors. It also focuses more on providing learning for partners on how to operate in a Value-Based Payment environment. Please see “How are they different? Cohort Management
Program Vs. Health Home Model” on pg. 32 of the Program Overview for more details on this and contact us if you have additional questions.


Q. What is the sustainability model for the Cohort Management Program?

A. This is a program that lasts through the end of DSRIP (March 2020). The program is not designed to be sustainable but to aid a network to develop a sustainable VBP model.


Q. What supports will be available after the pilot period is over (April 2020 and beyond)?

A. CCN, similar to all PPSs, is developing a sustainability plan in close collaboration with partners.

Network Formation & Roles

Q. How will networks form? Are partners expected to find/develop their own VLC or will they get grouped together by CCN?

A. Networks may form organically due to existing relationships and other PPS forums. Involvement in your RPU is strongly encouraged. CCN is also available to support network formation. Please see page 15 of the Program Overview for full details.


Q. Who determines the VLC for a network?

A. The VLC may lead the formation of a network and bring other partners to the table. Non-VLC agencies, like a nonprofit or community service provider, may organize a group of agencies and solicit a VLC to participate. It will be up to the VLC to agree to participate as they are taking on the responsibility for the network.


Q. Does the VLC reach out to partners they feel would benefit their cohort of interest?

A. Yes, the VLC may reach out to any partners they feel would benefit their particular cohort.


Q. Can one of the partners reach out to a potential VLC to get the process started with ideas?

A. Yes, CCN encourages CBOs to reach out to potential VLCs. Keep in mind VLCs may not have the personnel or capacity to respond to all inquiries.


Q. How do you get started and connect with other partners?

A. Please see the Interested Network Partners drop down list on for a list of available partners. There you will find the partner responses to CCN’s Participation Form indicating their interest in engaging with different types of cohorts. Feel free to reach out to your RPU representatives for contact information. CCN strongly encourages active participation at RPU meetings.


Q. What are the logistics of forming a cohort and network?

A. Please see the Program Overview, particularly Partnerships & Network Build Milestone, for steps necessary to start forming a network.


Q. If a network doesn’t have all the partners at the table at the beginning, what is the process for adding to what was in the original application?

A. Before a network can pass the Planning Phase Milestones, there needs to be a minimum of four distinct entities in a network, meeting the minimum composition requirements of one VLC, one referral source, and one Tier 1 CBO. The Network may add additional partners beyond these minimum requirements at any point in the planning process. If the network identifies there is a potential to add in a new partner, this would be coordinated through the VLC as the partner may need a Business Associate Agreement (BAA) with the VLC.


Q. How do you locate organizations who provide similar services?

A. CCN will be providing a list of interested partners, or you can contact your RPU representative.


Q. If we have a program that is already working, do we have to add in more CBOs?

A. If a program is already working, as long as the network meets the Cohort Management Program requirements of having one VLC, one referral source, one Tier 1 CBO and a total of at least four partners, then additional CBOs would not be mandatory.


Q. What specific services are available from CCN to support the network setup?

A. CCN Network Facilitators are available to help the network convene partners, facilitate meetings/record meeting minutes, help identify what is working well and not working well within the network, track and drive progress toward milestones, and assist VLC with Milestone documents. See Program Overview section on CCN Support Services for more details.


Q. What if an organization does not step forward to be a VLC in your region?

A. At present, all geographic areas of CCN’s PPSs have organizations that are interested in being a VLC. In the event that a VLC is not able to participate in the program, and a region is lacking a VLC, CCN will reach out to other potential VLCs to determine if they can meet the need.


Q. What is the benefit for the VLC?

A. VLCs will gain experience developing and coordinating a network effectively and efficiently to impact at-risk populations in a Value-Based Payment setting.


Q. How would multiple VLCs in the same network work?

A. CCN will only contract with one VLC per network.


Q. If a VLC is also a referral source, does there still need to be four partners?

A. There needs to be four distinct entities in a network at all times, meeting the minimum composition requirements of one VLC, one referral source, and one Tier 1 CBO.


Q. How many networks can a CBO participate with?

A. As many as they feel they have the capacity to support.


Q. Can the VLC also be a referral source?

A. Yes.


Q. If a partner has a corporate structure with separate entities, can those entities count as individual members of the network?

A. Yes, based on CCN’s historical approach to contracting, each contracting entity will be eligible to participate as a
network member. The intent of the program is to give partners the experience of working with other partners and aligning with community resources. As we’ve done in the past, we may pause acceptance of applications for the Cohort Management Program when one or more RPUs have met or exceeded attributed lives ratios.


Q. What can CCN do to facilitate partnerships with Managed Care Organizations
(MCOs) on behalf of the network?

A. CCN is aggregating success stories from its partners and intends to use existing MCO forums to expand knowledge of what is happening across the PPS. In addition to the Cohort Management Program, CCN has a Value-Based Payment (VBP) Incentive Program that is designed to prepare partners for success in a VBP arrangement. CCN has studied the VBP roadmap to align with the NYS vision for the future of healthcare delivery. CCN encourages partners with existing MCO relationships to invite them to the table wherever and whenever possible. MCOs are critical to the DSRIP transformation process.


Q. Can partners be involved in more than one network?

A. Yes, networks can serve more than one cohort.


Q. For organizations that have billable and non-billable Medicaid services, how are they classified?

A. Please see the Program Overview section on Basic Terminology Community Based Organization Tier Levels 1-3 to
understand your tier level. CCN follows the DOH definitions to determine classification.


Q. Can an organization be a VLC and CBO? How do I know which I am?

A. Yes, which role the organization will serve will depend on their qualifications and role in the network and the cohort. See Requirements of the VLC in the Program Requirements section and Basic Terminology section of the Project Overview for definitions on the roles.


Q. Where will accountability of partner performance lie? If a partner is under performing, what can happen?

A. Accountability for partner performance lies with the network. During the Planning Phase, the network will define performance standards and accountability through the completion of the three Milestones.


Q. If a VLC is a safety net CBO which bills Medicaid, can it continue to bill Medicaid as part of this program?

A. Yes, VLCs and CBOs will continue to bill for services as they currently do. CCN does not reimburse services already covered by Medicaid. See page 30 of the Program Overview for funded and unfunded services through the Cohort Management Program.


Q. If a partner has a grievance with their VLC, does that get escalated to CCN or stay within the network only?

A. During the Planning Phase, CCN strongly encourages network to discuss governance processes that will address grievances. CCN Network Facilitators have been trained to facilitate the resolution of Network issues.

Program Details

Q. When building a cohort, can we include Medicaid Members who are actively enrolled in a Health Home?

A. Yes, they are allowed to be included. The Cohort Management Program does not pay for direct patient services, unlike the Health Home Program. The Cohort Management Program pays for the network’s coordination of services and deliverables designed by the network.

When selecting a cohort, the cohort objectives need to tie to the DSRIP objectives to reduce avoidable admissions, avoidable readmissions, and avoidable emergency room visits. The network may want to consider: 1) selecting a cohort that members of the network are already working with within their organization(s), e.g., to achieve HEIDIS measures, PCMH requirements; 2) using the Cohort Launch List which identifies 20 potential measures which will help the PPS achieve the DSRIP metrics; 3) identifying a cohort that has been or may be difficult to impact, thus leveraging the Network’s learnings on how to deliver care differently for the cohort.


Q. If you are in a county with more than one PPS, how do you know if they are a DSRIP attributed life for Care Compass Network?

A. The CCN Network Facilitator assigned to the VLC/network can work with the CCN Population Health Department to identify Medicaid Members that are attributed to the CCN PPS. The network can still serve all Medicaid Members but will only be paid a PMPM rate for CCN attributed members.


Q. Is there a specifically defined area or counties to be served?

A. The network can serve any Medicaid Member in any county. The inclusion criteria will need to identify the triggering event for which the Medicaid Member becomes a cohort member. The network can still serve all Medicaid Members but will only be paid a PMPM rate for CCN attributed members.


Q. Can cohort members be Health Home enrollees?

A. Not necessarily. If the patient has a relationship with the VLC or network member, they continue with that relationship. The network will identify triggering events in which they will communicate with the patient what the plan of care is, who will be involved in their care, how the warm handoff will occur, and how information will be exchanged.


Q. Does a cohort member always have to be 18 years of age or older?

A. No, a cohort member can be younger than age 18 as long as the inclusion criteria does not exclude this.


Q. Is the 50-200 Medicaid Member requirement CBO specific or cohort-specific?

A. The cohort panel size is network specific.


Q. Would dual eligible clients be eligible?

A. Yes, dual eligible patients may be members of cohorts. See Program Overview, Active Management Phase, for specific details on funded and unfunded services of the program.


Q. Can Medicaid members be in more than one cohort?

A. Yes, Medicaid Members can be in more than one cohort as long as they fit the inclusion criteria. CCN will be monitoring this and if required, CCN will make determinations and use a standardized method to identify which is the appropriate network to serve the cohort.


Q. What are the deliverables?

A. Depending on the phase of contracting each network will be required to submit a monthly report to CCN through the VLC. During the Planning Phase, the VLC will be required to submit three Milestone Reports on behalf of the network. During the Active Management Phase, the VLC will submit a monthly list of cohort members in the network. The CCN Network Facilitator assigned to the network will work with the VLC to ensure successful submission.


Q. If you are a CBO delivering a specific program, can you include non-Medicaid Members in your cohort if you are not seeking reimbursement for them?

A. Yes.


Q. Can the cohort be a replication of something that already exists?

A. Yes.


Q. Is there a framework/template contract we can use between VLCs and network partners?

A. Yes, this can be found on the Cohort Management Program website under the toolkit.


Q. Are the contracts going to be totally new contracts or another Appendix C?

A. An Appendix C contract between CCN and the VLC will occur for the Planning Phase and the Active Management Phase. There will not be a contract between CCN and the other network partners. Network specific contracts will be determined between the VLC and the network organizations.

Data & Assessment

Q. In terms of data reporting, does CCN assume partners will go forward with the Care Management or Pop Health platform?

A. No. CCN assumes networks will use existing reporting infrastructure.


Q. Under what mechanism are we allowed to share PHI, etc.?

A. The HIPAA Privacy Rule governs the privacy of medical information deemed PHI by HIPAA and sets for the circumstances under which PHI can be shared. In general, providers and other HIPAA entities and their Business Associates must obtain written authorization by the individual who is the subject of the PHI or a legally authorized representative to disclose PHI, unless an exception applies. HIPAA supports certain exceptions for disclosure and sharing to allow for treatment and business operations. A Covered Entity may use or disclose PHI for “treatment”, “payment”, or “health care operations” without consent from the patient. There are more HIPAA resources at this website:

CCN requires that networks establish Business Associate Agreements (BAAs) among its partners to define the rights and obligations of both partners related to creating, receiving, maintaining PHI among the network. There is
more information about Business Associates and BAAs at this website:


Q. Where does the RHIO fit in?

A. Regional Health Information Organizations (RHIO) aggregate clinical data from across the community and can be a powerful resource to the networks and partners as they provide services to cohort members. In general, RHIOs maintain a community-wide record which integrates information from medical providers and other organizations from across the community. CCN recommends that partners reach out to their local RHIO to understand the benefits and responsibilities of accessing RHIO information.

Rochester RHIO:


Q. What assistance will be provided in pulling and managing data?

A. CCN will support the Networks management of data by offering the following:
• Secure File Transfer platform for file sharing and exchange.
• Recommended tracking templates to track information that CCN does not collect.

CCN will offer these enhanced services to Networks:
• Identify specific Medicaid Members for the Cohort Panel based on recent billing and claims data (CCN has a few different data sources and can access PHI level information). Depending on the chosen cohort, CCN may not be the ideal way to identify individuals.
• Pre-populate some elements of the Social Determinants and Clinical Needs Assessment
• Assist Networks to monitor short-term and long-term indicators for their cohort

See Program Overview, CCN Support Services for more information.


Q. What are the metrics?

A. CCN currently tracks partner level performance on several key DSRIP performance metrics. CCN is able to track network performance on the same metrics to identify trends among cohort members. CCN will work with the networks to configure set up in the Compass Hub. The metric list is below:

Q. How do we measure and show results?

A. During the Planning Phase Data Reporting Milestone, networks will define the performance indicators they will track as well as the DSRIP performance metrics that will be tracked by CCN. CCN will extend access to the Compass Hub dashboards to the networks for that information; however, there is significant claims lag. Thus, the networks are required to track current indicators to help guide their activities to improve outcomes.


Q. Is the $50,000 in Planning Funds regardless of size or geographic dispersion?

A. Yes, each network will receive $50,000 for Network planning, regardless of network characteristics.


Q. Is there anything in this program that forces the VLC to share a certain portion of the funds they receive with the Partner Organizations that are/will be in their network?

A. No, the disbursement and use of Network Planning funds is contingent upon the contractual negotiations between the VLC and network members. As the learnings from this process will inform future network relationships in a Value Based Payment environment, it is unlikely the network will form successfully if funds are not distributed fairly.


Q. How will the VLC invoice CCN and receive payment?

A. The VLC does not need to remit an invoice. During the Planning Phase, the VLC will receive full payment upon execution of a Planning Phase Appendix C. During the Active Management Phase, the VLC will receive a PMPM (Per Member Per Month) payment upon receipt of a patient panel.


Q. How is payment distributed from the VLC?

A. This is determined within the Network as CCN only pays the VLCs.


Q. How is the value of services determined?

A. This is determined by the network.


Q. Is there a revenue loss component?

A. Revenue loss is administered separately in the Fall of each calendar year.


Q. Can the VLC contract with an outside partner or CCN to manage its funds flow to the network?

A. Yes and no. Yes, the VLC can contract with an outside partner to manage funds flow to the network. No, CCN will not manage funds flow to the network. In part this is due to the 95/5 requirement which is why CCN is only flowing funds to the VLCs (which are also safety net organizations).


Q. Are there double-dipping risks (services already funded)?

A. CCN has analyzed the services that are currently funded to help ensure no double-dipping should occur. If there is any question or concern on this, please email


Q. As a VLC, how do we disburse funds fairly and equitably? For example, will partners which are less hands on, like a referral-only source, receive a smaller portion of the Active Management funding than those partners who are have a greater time and/or effort invested, like a case manager?

A. It is up to the network as a whole to come up with an agreed upon funds flow model. CCN has created a theoretical model for fund distribution for networks to use as a guide. This may be found under the Planning Funds Distribution Toolkit section of the cohort webpage.


Q. If there are a lot of partners in the network, how does CCN envision the funding being distributed?

A. It is up to the network to determine funds distribution.


Q. Does CCN evaluate the “fair and equitable” distribution of planning funds and
other funds to network partners?

A. No, the network partners best know the value of the services provided which determine fairness and equity and therefore it is up the them to determine this during the Planning Phase (See Program Overview, Network Build Milestone for more information).


Q. Can money be used for patient participation incentives?

A. You will need to seek legal counsel for this, however CCN has done very small incentives to patients for participation in CCN activities.


Q. How does a CBO access funding?

A. Through the VLC leading the network.


Q. This seems very staff intensive. Is the PMPM intended to cover the cost of
Administrative Support Staff (i.e. billing, clerical)?

A. The PMPM consists of two parts: Administrative Support/Reporting plus the time and effort of the partners in the network.


Q. Can a Health Home provider receive funds for Cohort Management as well as funds from Medicaid Health Home?

A. Yes. Please see “How are they different? Cohort Management Program Vs. Health Home Model” on pg. 32 of the
Program Overview for more details on this and contact us if you have additional questions.

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