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Specialty Care Incentive Measures

Effective date: Jan. 1–Dec. 31, 2025

Introduction

This page sets forth terms of the Specialty Care Incentive Program (“SCI Program”) offered by the Alliance, as described herein. The SCI Program compensates SCI Eligible Providers for providing access to specialty care services for Alliance Eligible Members and encourages specialty care physician participation in the Alliance Medi-Cal program.

Definitions

The following terms shall have the definitions contained in the section below. Capitalized terms used in this document and not otherwise defined herein shall have the meanings assigned to them in the Agreement.

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SCI Eligible Provider

An SCI Eligible Provider is an Alliance Participating Provider who has entered into a Referral Physician Services Agreement (“Agreement”), or a physician or Non-Physician Medical Practitioner of a group that has entered into a Referral Physician Services Agreement, with the Alliance, that is in effect at the end of the SCI Term. SCI Eligible Providers exclude emergency department physicians, hospitalists, pathologists and radiologists.

SCI Term

SCI Eligible Member

Non-Physician Medical Practitioner

Participating Provider(s)

General Terms

Policies regarding actual and proposed budget and cost allocations are subject to the approval of the Alliance. The Alliance shall have the sole discretion to establish binding policies regarding determination of incentive payments. The Alliance, in its sole and absolute discretion, may implement Specialty Care Incentive Programs for periods after completion of the SCI Term. Any such programs shall be on terms determined by the Alliance. The SCI Program does not contain any financial incentive or make any payment that acts directly or indirectly as an inducement to reduce or limit medically necessary covered services provided to a member.

Effect of Termination

In the event of the termination of the SCI Eligible Provider’s Agreement for any reason prior to the expiration of the SCI Term, the SCI Eligible Provider will only be eligible for payment of measures that are payable via claims for any services provided prior to the termination date.

SCI Program Measure Overview

The following table includes the names of the nine measures included in the SCI Program and a description of each measure's goal.

	Measure	Goal
1	Reduce OB C-Section Rate	Encourage appropriate delivery method that drives better outcomes for members.
2	Increase OB Referrals to Doulas	Encourage obstetrics and gynecology (OB) providers to refer patients to doulas.
3	Increase California Children Services (CCS) Referral Rate	Timely diagnostics and treatment for children with eligible medical conditions (such as cystic fibrosis, cerebral palsy, heart diseases) through referrals.
4	Increase Palliative Care Referrals	Reduce emergency visits and inpatient care through increase of referrals to a palliative care program.
5	Coordination with Primary Care Provider (PCP)	Increase data sharing and PCP collaboration.
6	Provider Completion of Activities to Support Regulatory Requirements	Improve Provider Satisfaction Survey responsiveness.
7	Provider Completion of Activities to Support DHCS	Demonstrate support of health equity initiatives through provider training to clinically integrate DEIB principles as required by DHCS.
8	Increase New Members Seen	Increase access to care for Alliance members and increase the number of members seen with timely access to care standards.
9	Emergency Department Follow-Up Visit	Reduce emergency department utilization and inpatient admissions. Encourage providers to see members within 14 days of an emergency room discharge.

SCI Measure Specifications

This section includes specifications for the 2025 SCI Program measures.

Measure 1 – Reduce OB C-Section Rate

Measure Description	Providers will receive payment for a reduction in cesarean deliveries for Eligible Members as compared to the baseline year and targets.
Related Documentation and Deadline	Provider must submit a report to the Alliance of all births for Eligible Members for the baseline calendar year of 2023 and measurement calendar year of 2025 no later than February 14, 2026. Reports must be provided using the Alliance’s report template and sent to the Alliance’s Finance Department via email to [email protected].
Calculation Specification	Eligible Provider: An SCI Eligible Provider who is an OBGYN or a certified nurse midwife. Eligible Member: An SCI Eligible Member 8-64 years of age in their first live birth, that are singleton (no twins or beyond) and in the vertex presentation (no breech or transverse positions) referred to as a Nulliparous Woman with a Term, Singleton Baby in a Vertex position (NTSV). Only Eligible Members who are discharged during the Measurement Year are included in the measurement, and members with a length of stay exceeding 120 days are excluded from this measure. Measure Period: This measure is applicable to deliveries performed by Eligible Provider for Eligible Members during the Measurement Year. Measurement Year: Calendar year 2025. Baseline Year: Calendar year 2023. All data used by the Alliance for the Baseline Year shall be captured using paid claims as of March 31, 2025. Total Measure Funding: $350,000. Percentage of Total Births: Calculated by dividing the Eligible Provider’s live births during the Baseline Year by the total number of NTSV live births for Alliance-contracted Eligible Providers during the Baseline Year. Provider Eligible Funding: Total Measure Funding * Percentage of Total Births. Baseline Rate: The number of live babies born at or beyond 37.0 weeks gestation to Eligible Members via cesarean delivery during the Baseline Year divided by the total NTSV live births during the Baseline Year. Target Rate: 29%. Tier 1 Rate: Baseline Rate - ((Baseline Rate – Target Rate) * 40%). The Tier 1 Rate is only applicable if the Baseline Rate is greater than the Target Rate. Tier 2 Rate: Baseline Rate - ((Baseline Rate – Target Rate) 60%). The Tier 2 Rate is only applicable if the Baseline Rate is greater than the Target Rate. Measurement Rate: The number of live babies born at or beyond 37.0 weeks gestation to Eligible Members via cesarean delivery during the Measurement Year divided by the total NTSV live births during the Measurement Year. Payment Amount: If Measurement Rate is less than or equal to Tier 2 Rate, Provider shall receive 100% of Provider Eligible Funds. If Measurement Rate is greater than Tier 2 Rate but less than or equal to Tier 1 Rate, Provider will receive 40% of Provider Eligible Funding. If Measurement Rate is greater than Tier 1 Rate, Provider will not receive any funding for this measure. If both Baseline Rate and Measurement Rate are less than or equal to Target Rate, Provider will receive 100% of Provider Eligible Funding. If Baseline Rate is less than or equal to Target Rate but Measurement Rate is higher than Baseline Rate and Target Rate, Provider will not receive any funding for this measure. Example1: Measurement Rate < Tier 2 Rate: Target rate: 29% Baseline Rate: 30.8% Tier 1 Rate: 30.8% - ((30.8%-29%) * 40%) = 30.1% Tier 2 Rate: 30.8% - ((30.8%-29%) * 60%) = 29.7% Measurement Rate: 28% Payment: 100% of Provider Eligible Funds Example 2: Measurement Rate < Tier 1 Rate but > Tier 2 Rate: Target rate: 29% Baseline Rate: 30.8% Tier 1 Rate: 30.8% - ((30.8%-29%) * 40%) = 30.1% Tier 2 Rate: 30.8% - ((30.8%-29%) * 60%) = 29.7% Measurement Rate: 29.9% Payment: 40% of Provider Eligible Funds Example 3: Measurement Rate is > Tier 1 Rate: Target rate: 29% Baseline Rate: 30.8% Tier 1 Rate: 30.8% - ((30.8%-29%) * 40%) = 30.1% Tier 2 Rate: 30.8% - ((30.8%-29%) * 60%) = 29.7% Measurement Rate: 32% Payment: 0% of Provider Eligible Funds Example 4: Baseline Rate and Measurement Rate are < Target Rate: Target rate: 29% Baseline Rate: 25% Tier 1 Rate: N/A Tier 2 Rate: N/A Measurement Rate: 24% Payment: 100% of Provider Eligible Funds Example 5: Baseline Rate is < Target Rate but Measurement Rate is > Target Rate: Target rate: 29% Baseline Rate: 25% Tier 1 Rate: N/A Tier 2 Rate: N/A Measurement Rate: 30% Payment: 0% of Provider Eligible Funds
Payment Frequency	Payment for this measure shall be made to Provider no later than March 31, 2026.

Measure 2 – Increase OB Referrals to Doulas

Measure Description	Providers will receive $100 for each referral provided to an Eligible Member for an Alliance contracted doula provider.
Related Documentation and Deadline	This measure is based on claims data. Providers are required to bill with code G9968 and modifier U1 to indicate that a referral to a doula provider was issued to an Eligible Member. All applicable claims must be received by the Alliance no later than January 31, 2026 and must be Complete Claims that are in a paid status to be counted toward this measure.
Calculation Specification	Eligible Provider: An SCI Eligible Provider who is an OBGYN. Eligible Member: An SCI Eligible Member who is eligible to receive doula services in accordance with DHCS requirements and is not already receiving doula services. Measure Period: This measure is applicable to doula referrals provided to Eligible Members during calendar year 2025. Measure Calculation: The Alliance will pay provider for doula referrals through claims payment when code G9968 is billed with modifier U1. Payment Amount: $100 for every eligible doula referral (limited to one referral per Eligible Member).
Payment Frequency	Payment for this measure will be made to Provider no later than 45 days after the end of quarters 1-3 of calendar year 2025 and 90 days after the end of quarter 4 of calendar year 2025.

Measure 3 – Increase California Children Services (CCS) Referral Rate

Measure Description	Providers contracted with the Alliance will receive $1,000 for each Eligible Member referred by the Eligible Provider to the California Children’s Services (CCS) program.
Related Documentation and Deadline	This measure is based on claims data. Providers are required to bill with code G9968 and modifier U2 to indicate that a referral to the applicable local county CCS office was issued for an Eligible Member. All applicable claims must be received by the Alliance no later than January 31, 2026 and must be Complete Claims that are in a paid status to be counted toward this measure.
Calculation Specification	Eligible Provider: An SCI Eligible Provider. Eligible Member: An SCI Eligible Member who meets the eligibility criteria defined for the CCS program per DHCS guidelines, and who is not already in the CCS program. Measure Period: This measure is applicable to CCS referrals provided to Eligible Members during calendar year 2025. Measure Calculation: The Alliance will pay providers for CCS referrals through claims payment when code G9968 is billed with modifier U2. Payment Amount: $1,000 for every eligible CCS referral provided for an Eligible Member (limited to one referral per Eligible Member).
Payment Frequency	Payment for this measure will be made to the Provider no later than 45 days after the end of quarters 1-3 of calendar year 2025 and 90 days after the end of quarter 4 of calendar year 2025.

Measure 4 – Increase Palliative Care Referrals

Measure Description	Providers will receive $100 for each Eligible Member referred to an Alliance contracted palliative care provider.
Related Documentation and Deadline	Eligible Providers must submit a referral to the Alliance to a palliative care provider. Only referrals with an effective date in 2025 will count toward this measure.
Calculation Specification	Eligible Provider: An SCI Eligible Provider. Eligible Member: An SCI Eligible Member who meets the eligibility criteria defined for palliative care per DHCS guidelines. Measure Period: This measure is applicable to palliative care referrals provided to Eligible Members during calendar year 2025. Measure Calculation: The Alliance will pay providers for palliative care referrals. Payment Amount: $100 for every eligible palliative care referral provided to an Eligible Member (limited to one referral per Eligible Member).
Payment Frequency	Payment for this measure shall be made to the Provider by no later than 45 days after the end of quarters 1-3 of calendar year 2025 and 90 days after the end of quarter 4 of calendar year 2025.

Measure 5 – Coordination with Primary Care Provider (PCP)

Measure Description	Providers will receive $25 for each Eligible Member where Eligible Provider communicates with the member’s PCP to share information relevant to the member’s care (e.g. treatment notes, care plan notes, etc.) within 30 days of Eligible Provider’s visit with Eligible Member.
Related Documentation and Deadline	This measure is based on claims data. Eligible Providers are required to bill with code G9968 and modifier U3 to signify that provider communicated with the Eligible Member’s PCP within 30 days of Eligible Provider’s visit with Eligible Member. All applicable claims must be received by the Alliance no later than January 31, 2026 and must be Complete Claims that are in a paid status to be counted toward this measure.
Calculation Specification	Eligible Provider: All SCI Eligible Providers. Eligible Member: An SCI Eligible Member. Measure Period: This measure is applicable to PCP Coordination provided for Eligible Members during calendar year 2025. Measure Calculation: The Alliance will pay provider for PCP Coordination through claims payment when code G9968 is billed with modifier U3. Payment Amount: $25 for every eligible PCP Coordination provided for an Eligible Member.
Payment Frequency	Payment for this measure shall be made to Provider no later than 45 days after the end of quarters 1-3 of calendar year 2025 and 90 days after the end of quarter 4 of calendar year 2025.

Measure 6 - Provider Completion of Activities to Support Regulatory Requirements

Measure Description	Providers will receive $100 for each Provider Satisfaction Survey submitted.
Related Documentation and Deadline	This measure is based on submission of completed Provider Satisfaction Surveys that have been completed by the Alliance’s survey vendor’s deadline. The Alliance’s Provider Satisfaction Survey vendor will only share the identity of the providers who complete the survey. The rest of the survey is anonymous.
Calculation Specification	Eligible Provider: An SCI Eligible Provider whose office is located within the counties of Mariposa, Merced, Monterey, San Benito or Santa Cruz, and who has been contacted by the Alliance’s survey vendor to complete the 2025 Provider Satisfaction Survey, is eligible for this payment. Eligible Member: N/A. Measure Period: This measure is applicable to Provider Satisfaction Surveys completed during calendar year 2025. Measure Calculation: The Alliance will pay providers for each Provider Satisfaction Survey completed per Eligible Provider. Payment Amount: $100 for every eligible Provider Satisfaction Survey completed as verified by the Alliance’s vendor.
Payment Frequency	Payment for this measure shall be made to Providers by no later than March 31, 2026.

Measure 7 – Provider Completion of Activities to Support DHCS

Measure Description	Providers will receive $200 for each completed health equity training provided by the Alliance per DHCS requirements as noted in All Plan Letter (APL) 23-025. Providers who participate in the Alliance DEIB training must complete one of the following trainings: the online learning management system training (log in with name, email and attestation) or an in-person Alliance specific DEIB training (sign in sheet attendance required).
Related Documentation and Deadline	Eligible Provider must ensure that all documentation requirements specified by DHCS for health equity trainings are completed prior to the end of calendar year 2025.
Calculation Specification	Eligible Provider: An SCI Eligible Provider. Eligible Member: N/A. Measure Period: This measure is applicable to health equity trainings completed in 2025. Measure Calculation: The Alliance will pay providers for each health equity training completed per Eligible Provider. Payment Amount: $200 for every eligible health equity training completed.
Payment Frequency	Payment for this measure shall be made to Providers by no later than March 31, 2026.

Measure 8 – Increase New Members Seen

Measure Description

Providers will receive payment for an increase in New Member Visits in the Measurement Quarter as compared to the Baseline Quarter.

Related Documentation and Deadline

Eligible Provider must submit claim no later than February 14, 2026. Claims must be Complete Claims that are in a paid status in order to count for this measure for each Measurement Quarter.

Calculation Specification

Eligible Provider: An SCI Eligible Provider.
Eligible Member: An SCI Eligible Member.
New Member Visits: New patient visits or consultations for Eligible Members properly billed in accordance with Current Procedural Terminology (CPT®) guidelines as initial encounters using one of the following codes: 99202, 99203, 99204, 99205, 99242, 99243, 99244, 99245, 99252, 99253, 99254, 99255.
Measure Period: This measure is applicable to New Member Visits conducted during each Measurement Quarter.
Measurement Quarter: The quarter of calendar year 2025 being used to calculate the measure.
Baseline Quarter: The quarter of calendar year 2024 being compared against the Measurement Quarter (e.g. Q1 2024 vs. Q1 2025). All data used by the Alliance for each Baseline Quarter shall be captured using paid claims as of March 31, 2025.
Baseline Number: The total number of New Member Visits during the Baseline Quarter.
Measurement Number: The total number of New Member Visits during the Measurement Quarter.
Improvement Number: The Measurement Number minus the corresponding Baseline Number.
- Example: 24 New Member Visits in Q1 2025 – 10 New Member Visits in Q1 2024 = 14
Percent of Improvement: Improvement Number divided by the Baseline Number.
Tiers: There are five tiers associated with this measure, which have corresponding percentages and rates.

Tier	Percent Range	Lower Percent	Upper Percent	Rate/ Improvement Number
1	1-5%	1%	5%	$50
2	6-10%	6%	10%	$100
3	11-15%	11%	15%	$150
4	16-20%	16%	20%	$200
5	Over 20%	>20%	100%	$200

Measure Calculation: The Improvement Number shall be distributed into the above Tier(s) based on the Improvement Percent for each Measurement Quarter, rounding to the nearest full member. If rounding results in a full member that falls between the upper range of a lower Tier and lower range of a higher Tier, the member will be rounded up into the higher Tier.
Tiers 1-4:
- If the Percent of Improvement is greater than the Tier’s Upper Percent, a portion of the Improvement Number shall be distributed to the Tier using the following formula: (Baseline Number * (1+Upper Percent)) - Baseline Number.
- If the Percent of Improvement is greater than or equal to the Tier’s Lower Percent but below the Tier’s Upper Percent, the total Improvement Number less distribution to lower tiers, where applicable, shall be distributed to the Tier.
- If the Percent of Improvement is less than the Tier’s Lower Percent, no portion of the Improvement Number shall be allocated to the Tier.
- If there is no Baseline Number, five percent of the Measurement Number shall be allocated to Tiers 1-4.
Tier 5:
- If the Percent of Improvement is over 20%, the remaining portion of the Improvement Number shall be added to Tier 5.
Payment Amount: The Alliance shall allocate the Improvement Number across the Tier(s). Each number in a tier (the allocated Improvement Number) will be paid per the rate indicated in the above table. The Alliance shall pay Provider the sum of the total rates for Improvement Numbers allocated in each Tier.
Example 1: Provider with 20% improvement
Baseline Number: 50
Measurement Number: 60
Improvement Number: 10
Improvement Percent: 20%

Tier	Allocation	Rate	Total Earned
1	2	$50	$100
2	3	$100	$300
3	2	$150	$300
4	3	$200	$600
5	0	$200	$0
Total Payment			$1,300

Example 2: Provider with 5% improvement
Baseline Number: 100
Measurement Number: 105
Improvement Number: 5
Improvement Percent: 5%

Tier	Allocation	Rate	Total Earned
1	5	$50	$250
2	0	$100	$0
3	0	$150	$0
4	0	$200	$0
5	0	$200	$0
Total Payment			$250

Example 3: Provider with 13% improvement
Baseline Number: 100
Measurement Number: 113
Improvement Number: 13
Improvement Percent: 13%

Tier	Allocation	Rate	Total Earned
1	5	$50	$250
2	5	$100	$500
3	3	$150	$450
4	0	$200	$0
5	0	$200	$0
Total Payment			$1,200

Example 4: Provider with 22.22% improvement
Baseline Number: 90
Measurement Number: 110
Improvement Number: 20
Improvement Percent: 22.22%

Tier	Allocation	Rate	Total Earned
1	4	$50	$200
2	5	$100	$500
3	4	$150	$600
4	5	$200	$1,000
5	2	$200	$400
Total Payment			$2,700

Example 5: Provider with 100% improvement (no baseline)
Baseline Number: No Baseline
Measurement Number: 10
Improvement Number: 10
Improvement Percent: 100%

Tier	Allocation	Rate	Total Earned
1	1	$50	$50
2	1	$100	$100
3	1	$150	$150
4	1	$200	$200
5	6	$200	$1,200
Total Payment			$1,700

Payment Frequency

The Alliance will pay the Provider no later than 45 days after the end of quarters 1-3 of calendar year 2025 and 90 days after the end of quarter 4 of calendar year 2025.

Measure 9 – Emergency Department Follow-Up Visit

Measure Description	Providers will receive $50 for each applicable claim for an Eligible Member who was seen by an Eligible Provider within 14 days after being discharged from an emergency department (ED) visit.
Related Documentation and Deadline	This measure is based on claims data. All applicable claims must be received by the Alliance no later than February 14, 2026 to be counted toward this measure and must be Complete Claims that are in a paid status.
Calculation Specification	Eligible Provider: An SCI Eligible Provider. Eligible Member: An SCI Eligible Member who was discharged from an ED with 14 days of seeing an Eligible Provider. Measure Period: This measure is applicable to visits occurring in 2025. Measure Calculation: The Alliance will pay an Eligible Provider under this measure for each eligible visit that occurs within 14 days of an Eligible Member’s discharge from an ED. The Alliance will identify eligible visits via claims, which are Complete Claims that are in a paid status no later than 90 days following the end of each quarter of calendar year 2025. Payment Amount: $50 for every eligible visit under this measure.
Payment Frequency	Payment shall be made to Providers for this measure no later than March 31, 2026.