Primary Care First (PCF) is the CMS Innovation Center's flagship advanced primary care payment model, and the most concrete operational example of what value-based primary care looks like in Medicare today. Built on the lessons of CPC and CPC+, PCF combines a five-tiered prospective Population-Based Payment, a Flat Primary Care Visit Fee that replaces most evaluation and management billing, and a Performance-Based Adjustment tied to quality and acute hospital utilization. For selected Georgia primary care practices operating under PCF, the model represents an entirely different revenue architecture from traditional fee-for-service: predominantly prospective, accountable for outcomes, and providing Advanced APM status that qualifies clinicians for Qualifying APM Participant (QP) determination and MIPS exemption.
This guide explains how PCF works, who participates, how payment flows, how performance is measured, what PCF means for Georgia beneficiaries and clinicians, and how PCF relates to the broader CMMI portfolio and its successor model Making Care Primary (MCP).
- PCF payment structure: Population-Based Payment (prospective monthly capitation) + Flat Primary Care Visit Fee (replaces most E/M billing) + Performance-Based Adjustment (based on quality and acute hospital utilization)
- Two cohorts: Cohort 1 and Cohort 2, each with a five-year performance period
- Advanced APM status: PCF qualifies clinicians for Qualifying APM Participant (QP) determination, MIPS exemption, and APM incentive payments
- Georgia eligibility: Georgia is one of the PCF-eligible regions; selected primary care practices participate across both cohorts
- Beneficiary experience: No enrollment required, no extra cost, no change in benefits; PCF effects show up as better access and care management
The statutory and regulatory foundation
PCF rests on a series of overlapping authorities:
- Section 1115A of the Social Security Act: the CMS Innovation Center statutory framework, added by the Affordable Care Act. PCF is a CMMI model tested under Section 1115A authority.
- Section 1833(z) SSA: Advanced Alternative Payment Model (Advanced APM) and Qualifying APM Participant (QP) framework, added by MACRA. PCF is structured as an Advanced APM, qualifying participating clinicians for QP status when payment-amount or patient-count thresholds are met.
- CMMI Primary Care First Request for Applications (2019): the original PCF model RFA establishing Cohort 1 selection criteria.
- PCF Participation Agreements: the legal contract between CMS and each participating practice, signed for each cohort.
- Annual model implementation guidance: operational details published by CMMI between performance years.
PCF is not codified in 42 CFR Part 414 or other generally applicable Medicare regulations. Instead, the model operates through CMMI demonstration authority, with details set out in Participation Agreements and implementation guidance. This is normal for CMMI models, which are tested under Section 1115A authority rather than implemented through full notice-and-comment rulemaking.
The PCF cohorts and performance periods
PCF launched in two cohorts:
Cohort 1
- Selection completed 2020
- Five-year performance period beginning Performance Year 2021
- Multiple participating practices nationwide at launch
- Operating across multiple PCF-eligible regions
Cohort 2
- Selection completed 2021
- Five-year performance period beginning Performance Year 2022
- Additional participating practices
Cohort 1 PCF ends with Performance Year 2025; Cohort 2 PCF ends with Performance Year 2026. CMMI's successor model, Making Care Primary (MCP), has since launched in a first wave of states (Georgia is not in the first wave) with a longer multi-year performance period.
The PCF payment structure: Total Primary Care Payment (TPCP)
PCF replaces the bulk of traditional fee-for-service primary care payment with a three-component Total Primary Care Payment (TPCP) structure:
1. Population-Based Payment (PBP): prospective monthly capitation
The PBP is a per-beneficiary per-month (PBPM) prospective payment paid monthly to the practice. Beneficiaries are placed into one of five risk-adjusted PBP tiers based on Hierarchical Condition Categories (HCC) risk scores:
- Tier 1: lowest risk
- Tier 2: low-moderate risk
- Tier 3: moderate-high risk
- Tier 4: highest risk
- SIP Tier: Seriously Ill Population (see below)
The PBP is paid prospectively (in advance of services) and is not contingent on any specific visit occurring. It is the practice's reward for being responsible for the beneficiary's primary care.
2. Flat Primary Care Visit Fee (FPCVF)
In place of traditional E/M billing (CPT 99202-99215), PCF practices bill a flat per-visit fee per qualifying primary care visit. This applies to in-person and certain telehealth visits with the practice. The FPCVF simplifies billing for primary care encounters and reduces administrative burden compared to the E/M coding structure.
Some procedures and specialty services continue to be billed under traditional fee-for-service rates; the FPCVF replaces primarily the E/M component of primary care encounters.
3. Performance-Based Adjustment (PBA)
Each year, CMS calculates a Performance-Based Adjustment that can adjust the PBP by a capped percentage in either direction. The PBA is based on:
- Quality performance: measured against five PCF Quality Measures (described below)
- Acute Hospital Utilization (AHU): risk-adjusted measure of acute inpatient hospital admissions for the practice's attributed beneficiaries
Practices with strong quality and low AHU receive substantial upward adjustments to their PBP; practices with weak quality or high AHU face downward adjustments. The PBA is the central performance incentive of PCF, beyond the prospective PBP itself.
TPCP in practice
For a typical higher-risk beneficiary with multiple primary care visits in a year, total PCF payment combines the prospective PBP, per-visit FPCVF fees for each qualifying visit, and a PBA adjustment based on practice-level quality and AHU performance.
This compares to traditional fee-for-service primary care, which would generate revenue only when visits occurred and would be far more sensitive to visit volume. PCF practices have stable monthly revenue independent of visit count.
The Seriously Ill Population (SIP) component
PCF includes a separate Seriously Ill Population (SIP) component for Medicare beneficiaries who:
- Are seriously ill (e.g., advanced cancer, end-stage heart failure, severe COPD)
- Have significant functional decline
- Are not receiving adequate primary care
- Could benefit from intensive primary care coordination
SIP beneficiaries are referred to PCF practices for short-duration intensive care management. SIP carries a higher capitated payment than the standard PBP tiers (reflecting higher care management intensity) and is structured as a separate enrollment from the regular PCF beneficiary panel.
Not all PCF practices participate in the SIP component; participation in SIP is a separate election by the practice.
Advanced APM status and the Quality Payment Program
PCF is structured as an Advanced APM under Section 1833(z) SSA. This means PCF satisfies the three Advanced APM criteria:
- CEHRT use: PCF requires certified electronic health record technology
- Quality measurement: PCF includes Quality Measures comparable to MIPS
- Risk-bearing: PCF practices bear meaningful downside risk through the PBA
Advanced APM status drives Qualifying APM Participant (QP) determination under Section 1833(z). QP thresholds are set by CMS for each performance year based on payment-amount and patient-count measures.
PCF clinicians who achieve QP status receive:
- Earlier performance years: APM Incentive Payment (paid in PY+2)
- Later performance years: Qualifying APM Conversion Factor differential (replaces earlier incentive payments)
- MIPS exemption: QPs are entirely exempt from MIPS reporting and adjustment
Partial QPs may elect MIPS via the APM Performance Pathway (APP); non-QP MIPS-eligible PCF clinicians use APP. This integration ties PCF into the broader QPP framework and is one of the reasons primary care practices pursue PCF, given the combination of prospective payment, performance incentives, and Advanced APM benefits.
The PCF Quality Measures
PCF measures quality on a focused set of measures (changing modestly across performance years):
- Patient experience: CAHPS for PCF Patient Experience Survey
- Controlling High Blood Pressure: eCQM
- Diabetes HbA1c Poor Control: eCQM
- Colorectal Cancer Screening: eCQM
- Advance Care Planning: clinical quality indicator (refined across performance years)
Quality submission uses Certified Electronic Health Record Technology (CEHRT) and eCQM reporting. PCF practices must achieve performance thresholds on these measures for the Quality component of the PBA.
The Acute Hospital Utilization (AHU) measure
The AHU measure is the second component of the PBA. AHU is calculated as a risk-adjusted rate of acute inpatient hospital admissions per beneficiary per year for the practice's attributed PCF beneficiaries. Practices with lower AHU than expected (controlling for HCC risk) receive favorable PBA; practices with higher AHU than expected receive unfavorable PBA.
AHU reflects PCF's underlying theory of change: strong primary care should reduce acute hospital utilization. The AHU component creates a direct financial incentive for practices to invest in care management, after-hours access, and chronic disease management.
Beneficiary attribution
PCF beneficiaries are attributed to participating practices via two methods:
Voluntary alignment
- Beneficiary self-attests to selecting the practice as their primary care provider
- Submitted via MyMedicare.gov or Medicare.gov
- Beneficiary maintains complete Medicare FFS benefits and rights
Claims-based attribution
- For beneficiaries who do not self-attest
- Based on plurality of primary care services received from the PCF practice
- Recalculated periodically
Attributed beneficiaries do not lose any Medicare benefits or freedom of choice. They can see any Medicare provider, can change practices, and retain all standard Medicare protections. PCF is invisible to beneficiaries operationally; they do not enroll, do not pay extra, and may not even know their practice participates in PCF.
PCF-eligible regions
PCF launched across multiple eligible regions, including:
- Alaska, Arkansas, California, Colorado, Delaware, Florida, Georgia, Hawaii, Kansas City Region, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Montana, Nebraska, New Hampshire, New Jersey, New York, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Philadelphia Region, Rhode Island, Tennessee, Virginia
Georgia practices were eligible to apply in both Cohort 1 and Cohort 2 selection cycles.
Georgia practice participation
Selected Georgia primary care practices participate in PCF across Cohort 1 and Cohort 2. Participating Georgia practices generally fall into several categories:
Independent primary care groups
- Internal medicine and family medicine practices
- Geriatric medicine practices
- Often physician-owned multi-clinician groups
FQHC participation (limited)
- Some Georgia Federally Qualified Health Centers participate in PCF where eligibility criteria are met
- FQHC PCF participation requires PCF payment to coexist with FQHC PPS payment under careful structuring
Integrated system-affiliated practices
- Some primary care practices affiliated with Wellstar, Piedmont, Northside, or Emory participate where the affiliated practice meets independent eligibility criteria
Aledade Georgia
- Aledade's primary focus is MSSP, but some Aledade Georgia practices may also participate in PCF where appropriate
Privia Medical Group Georgia
- Selected Privia primary care practices participate where eligibility criteria are met
The specific list of Georgia PCF practices is not publicly published in fine detail; CMS maintains the official participant list and updates it periodically. Beneficiaries who want to know whether their primary care practice participates in PCF should ask the practice directly.
Georgia beneficiary experience
For Georgia Medicare beneficiaries whose primary care practice participates in PCF:
- No enrollment required: beneficiaries do not enroll in PCF and cannot opt out
- No additional cost: PCF involves no extra cost or premium for beneficiaries
- No change in benefits: beneficiaries retain all Medicare FFS benefits and freedom of choice
- Possible better access: PCF practices may invest in after-hours access, care management, and patient outreach
- Possible better coordination: PCF practices may have stronger care coordination infrastructure
- No prior authorization for primary care visits: primary care access remains unchanged
For most Georgia beneficiaries, PCF is operationally invisible. The model's effects show up indirectly through practice investment in better primary care services.
How PCF relates to other Medicare value-based-care frameworks
Relationship to MSSP
- PCF and MSSP are separate models
- A practice can participate in PCF, MSSP, or neither, but PCF practices generally focus on PCF rather than MSSP
- If a beneficiary is attributed to both an MSSP ACO and a PCF practice, attribution rules determine final assignment (PCF takes precedence for the practice's attributed beneficiaries)
Relationship to QPP/MIPS
- PCF clinicians who achieve QP status are MIPS-exempt
- PCF clinicians who are Partial QPs may elect MIPS via APP
- PCF clinicians who are MIPS-eligible non-QPs use APP for MIPS reporting
- PCF cannot combine with MVPs (PCF participants generally use APP if MIPS-eligible)
Relationship to other CMMI primary care models
- CPC and CPC+: predecessors; PCF refined the CPC+ payment design with stronger prospective payment and higher PBA exposure
- Making Care Primary (MCP): successor; launched in a first wave of states (Georgia not first wave); multi-year performance period; three tracks
Relationship to ACO REACH
- ACO REACH and PCF are distinct models
- A PCF practice generally would not also be in ACO REACH (single Advanced APM focus is standard)
- Both qualify as Advanced APMs for QP determination
14 best practices for PCF practices
- Invest in care management staffing: PBP funds care management; capture the benefit by investing in care managers, social workers, and patient navigators
- Optimize after-hours access: reduces AHU; consider open-access scheduling and after-hours phone triage
- Strong chronic disease management: diabetes, hypertension, and CHF management drive both quality scores and AHU
- Risk capture: accurate HCC coding ensures appropriate PBP tier assignment; under-coding leaves money on the table
- eCQM reporting maturity: quality submission via CEHRT is required; ensure EHR can support eCQM extraction
- Annual Wellness Visit (AWV) and ACP: drive quality measure performance and beneficiary engagement
- Patient experience focus: CAHPS for PCF is a core quality measure; train staff on patient communication and access
- Care coordination with specialists and hospitals: strong transitions reduce AHU
- Population health analytics: identify high-risk beneficiaries proactively and target interventions
- SIP participation evaluation: if your practice can support intensive care management for seriously ill patients, SIP participation provides additional revenue
- Voluntary alignment outreach: encourage attributed beneficiaries to confirm voluntary alignment for attribution certainty
- Behavioral health integration: depression and anxiety screening and treatment drive primary care outcomes
- Telehealth use thoughtfully: telehealth visits qualify for FPCVF where covered, expanding access
- Engage QPP Service Center and Acentra Health QIO: free technical assistance available for QP determination and APP if MIPS-eligible
14 common PCF issues
- Confusion about FPCVF replacing E/M: practices may continue submitting E/M codes by habit, requiring billing system reconfiguration
- HCC undercoding: practices accustomed to E/M minimum-documentation undercode chronic conditions, lowering PBP tier
- Under-investing in care management: practices that treat PBP as visit-replacement revenue (rather than care management investment) miss the model's full value
- AHU surprises: practices unaware of their AHU baseline see PBA swings they did not anticipate
- eCQM extraction failures: EHR configuration issues prevent quality measure reporting, harming PBA
- Voluntary alignment ambiguity: beneficiaries unaware of self-attestation may be claims-attributed elsewhere
- SIP participation underused: practices that could support SIP do not elect it
- Specialist referrals: over-referral to specialists weakens primary care's coordinating role
- After-hours access gaps: practices without after-hours access drive avoidable ED visits
- Transitions of care misses: failure to follow up after hospitalization drives readmission and AHU
- QP threshold tracking: practices unaware of QP determination snapshots may miss QP status
- APP reporting: non-QP PCF clinicians who are MIPS-eligible must submit APP at the APM Entity level
- Risk-adjustment volatility: annual HCC recalculation can shift beneficiaries between tiers
- Cohort 1 vs. Cohort 2 timing: practices in different cohorts have different sunset dates (PY 2025 vs. PY 2026)
Six worked examples: Georgia Medicare beneficiaries in PCF
1. Fulton 70: Atlanta PCF Cohort 1
A 70-year-old Atlanta retiree with hypertension and Type 2 diabetes is attributed via voluntary alignment to an independent Atlanta internal medicine practice in PCF Cohort 1. Her practice receives a Tier 3 PBP prospective monthly payment, bills FPCVF for her annual primary care visits, and receives PBA based on practice-level quality and AHU performance. She experiences PCF as her usual primary care, with additional care manager outreach and proactive medication management.
2. DeKalb 75: DeKalb PCF SIP
A 75-year-old DeKalb beneficiary with advanced heart failure and CKD Stage 4 is referred to a DeKalb PCF practice's SIP component. The practice receives a higher capitated SIP payment than standard PBP, supporting intensive care management: home visits, frequent telephone outreach, advance care planning, and tight coordination with cardiology and nephrology. The SIP enrollment is time-limited; once the beneficiary stabilizes or graduates, he may transition to standard PCF attribution.
3. Cobb 68: Cobb PCF Cohort 2
A 68-year-old Cobb beneficiary with COPD and Type 2 diabetes is attributed to a Cobb PCF Cohort 2 practice. Tier 3 PBP prospective payment, per-visit FPCVF billing, and PBA performance similar to the Cohort 1 example. He participates in the practice's diabetes self-management education program and benefits from the practice's investment in chronic disease management staff funded by PCF revenue.
4. Worth County 72: Albany Area FQHC PCF
A 72-year-old Worth County rural beneficiary is attributed to an Albany-area FQHC participating in PCF. The FQHC receives PCF payment alongside FQHC PPS payment under structured rules. Care management includes transportation support and language interpretation services. Tier 3 PBP based on HCC risk. The FQHC's PCF participation funds expanded primary care access for an underserved rural Medicare population.
5. Bibb 80: Macon PCF geriatric
An 80-year-old Bibb beneficiary with dementia, hypertension, and Type 2 diabetes is attributed to a Macon geriatric medicine practice in PCF. His Tier 4 PBP reflects his high HCC risk score. The practice provides comprehensive geriatric care including caregiver support, medication review, and advance care planning. Higher PBP funds the intensive care management his geriatric care requires.
6. Hall 67: Gainesville PCF
A 67-year-old Hall County beneficiary with hypertension and hyperlipidemia is attributed to a Gainesville family medicine practice in PCF. Tier 2 PBP reflects lower complexity and lower HCC risk. He receives preventive care, annual wellness visits, and ongoing medication management. His practice's PCF revenue supports a small care management team that periodically reaches out to higher-risk patients in the panel.
Frequently asked questions
General PCF questions
1. What is Primary Care First (PCF)?
PCF is a CMS Innovation Center primary care payment model that combines prospective Population-Based Payment, a Flat Primary Care Visit Fee replacing E/M billing, and a Performance-Based Adjustment based on quality and acute hospital utilization. PCF is structured as an Advanced APM under Section 1833(z) SSA.
2. Who runs PCF?
The CMS Innovation Center (CMMI) operates PCF under Section 1115A SSA authority.
3. When does PCF operate?
Cohort 1 runs for a five-year performance period beginning Performance Year 2021. Cohort 2 runs for a five-year performance period beginning Performance Year 2022.
4. Does Georgia have PCF practices?
Yes. Georgia is one of the PCF-eligible regions. Selected Georgia primary care practices participate in both cohorts.
5. What is Total Primary Care Payment (TPCP)?
TPCP is the combined PCF payment to the practice, consisting of Population-Based Payment (prospective monthly capitation), Flat Primary Care Visit Fee (per-visit payment replacing E/M), and Performance-Based Adjustment (a capped adjustment on PBP).
Payment questions
6. What is the Population-Based Payment (PBP)?
The PBP is a per-beneficiary per-month prospective payment paid to the practice for being responsible for the beneficiary's primary care. PBPs vary across five risk-adjusted tiers reflecting HCC risk scores.
7. What is the Flat Primary Care Visit Fee (FPCVF)?
The FPCVF is a fixed flat fee per qualifying primary care visit, replacing the bulk of traditional E/M billing for PCF practices.
8. What is the Performance-Based Adjustment (PBA)?
The PBA can adjust the PBP by a capped percentage in either direction based on the practice's quality performance and Acute Hospital Utilization (AHU) measure.
9. Is the PBP risk-adjusted?
Yes. PBPs reflect Hierarchical Condition Categories (HCC) risk scores. Higher-risk beneficiaries are placed into higher PBP tiers.
10. Do practices keep PCF payments regardless of visits?
Yes. The PBP component is prospective and paid monthly regardless of whether visits occur. The FPCVF is paid per visit; the PBP is the prospective component.
Beneficiary questions
11. Do Medicare beneficiaries enroll in PCF?
No. Beneficiaries do not enroll in PCF. They retain full Medicare FFS benefits and freedom of choice. PCF is an arrangement between CMS and the practice, with beneficiaries attributed to practices.
12. Can beneficiaries opt out of PCF?
PCF is invisible operationally; there is nothing for beneficiaries to opt out of. Beneficiaries can always change primary care practices if they prefer.
13. Does PCF cost Medicare beneficiaries anything extra?
No. There is no additional cost or premium for beneficiaries.
14. Do beneficiaries lose any Medicare benefits in PCF?
No. Beneficiaries retain all Medicare FFS benefits and rights, including freedom to see any Medicare provider.
Advanced APM / QP questions
15. Is PCF an Advanced APM?
Yes. PCF satisfies the three Advanced APM criteria (CEHRT use, quality measurement, meaningful risk) and qualifies as an Advanced APM under Section 1833(z) SSA.
16. Can PCF clinicians achieve Qualifying APM Participant (QP) status?
Yes. PCF clinicians can achieve QP or Partial QP status based on QP determination snapshots and threshold testing.
17. What does QP status provide for PCF clinicians?
QPs are MIPS-exempt and receive APM Incentive Payments in earlier performance years or the Qualifying APM Conversion Factor differential in later performance years.
18. Can PCF clinicians use the APM Performance Pathway (APP)?
PCF clinicians who are not QPs but are MIPS-eligible can use APP, which provides streamlined MIPS reporting for MIPS APM participants. PCF clinicians cannot combine PCF with MVPs.
Quality and AHU questions
19. What quality measures does PCF use?
PCF measures patient experience (CAHPS for PCF), controlling high blood pressure, Diabetes HbA1c Poor Control, colorectal cancer screening, and advance care planning (with some changes across performance years).
20. What is the Acute Hospital Utilization (AHU) measure?
AHU is a risk-adjusted measure of acute inpatient hospital admissions for the practice's attributed beneficiaries, used along with quality performance to determine the Performance-Based Adjustment.
21. What is the Seriously Ill Population (SIP) component?
SIP is a separate PCF component for Medicare beneficiaries with serious illness or significant functional decline. SIP carries a higher capitated payment than standard PBP and supports intensive care management.
Future and successor questions
22. What is Making Care Primary (MCP)?
MCP is the CMS Innovation Center's successor primary care transformation model, launched in a first wave of states. Georgia is not in the first wave. MCP has a multi-year performance period and three tracks.
23. Will PCF expand or be extended?
CMMI has indicated PCF will sunset at the end of its performance period for each cohort (PY 2025 for Cohort 1, PY 2026 for Cohort 2). MCP is the successor framework.
24. Where can Georgia practices learn more about PCF?
The CMS Innovation Center (innovation.cms.gov) maintains PCF model resources. The QPP Service Center (1-866-288-8292) handles QP and APP questions. Acentra Health QIO (1-844-455-8708) provides free technical assistance to Georgia practices.
25. Where can Georgia beneficiaries learn whether their practice participates in PCF?
Ask your primary care practice directly. CMS does not generally publish individual practice participation lists in a beneficiary-friendly format.
Contact resources
Federal Medicare resources
- Medicare (general): 1-800-MEDICARE (1-800-633-4227)
- CMS Innovation Center: innovation.cms.gov
- QPP Service Center: 1-866-288-8292 (quality payment program, APM, QP, APP)
- Palmetto GBA (Part A/B MAC Jurisdiction J): 1-866-238-9650 (claims processing)
Georgia state resources
- GeorgiaCares SHIP: 1-866-552-4464 (free Medicare counseling)
- 211 Georgia: 2-1-1 (information and referrals)
- Georgia Department of Community Health: dch.georgia.gov
- Georgia Aging and Disability Resource Connection: 1-866-552-4464
Beneficiary advocacy
- Medicare Rights Center: 1-800-333-4114 (federal Medicare counseling)
- Eldercare Locator: 1-800-677-1116
- Atlanta Legal Aid: 404-377-0701 (metro Atlanta)
- Georgia Legal Services: 1-800-498-9469 (statewide non-metro)
- Acentra Health QIO: 1-844-455-8708 (Georgia QIO, free technical assistance to providers)
Federal benefit administration
- Social Security Administration: 1-800-772-1213
- Benefits Coordination & Recovery Center (BCRC): 1-855-798-2627
Practice resources
- NAACOS: naacos.com (ACO and primary care advocacy)
- AMA QPP resources: ama-assn.org
- Medical Association of Georgia (MAG): mag.org
Why PCF matters
PCF is the most operationally tangible example of advanced primary care payment in Medicare today, and the foundation for how Medicare may pay primary care in the future. Its combination of prospective Population-Based Payment, simplified Flat Primary Care Visit Fee, substantial Performance-Based Adjustment, and Advanced APM status creates a fundamentally different incentive structure than fee-for-service. For Georgia primary care practices, PCF demonstrates what value-based primary care can look like; for Georgia beneficiaries, PCF represents the practices most likely to invest in better access, care management, and chronic disease management. Whether through PCF Cohort 1, Cohort 2, or the successor Making Care Primary (MCP) model, advanced primary care payment is here to stay, and Georgia's participation in PCF places selected primary care practices and their patients at the leading edge of that transformation.
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