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Section 438.6 Department of Health and Human Service preprint

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Department of Health and Human Services Section 438.6(c) Preprint – 07/31/17
Centers for Medicare & Medicaid Services STATE: ________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #52). The time required to
complete this information collection is estimated to average 1 hour per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
1
______________________________________________________________________________
Section 438.6(c) Preprint
______________________________________________________________________________
Section 438.6(c) provides States with the flexibility to implement delivery system and provider
payment initiatives under MCO, PIHP, or PAHP Medicaid managed care contracts. Section
438.6(c)(1) describes types of payment arrangements that States may use to direct expenditures
under the managed care contract – paragraph (c)(1)(i) provides that States may specify in the
contract that managed care plans adopt value-based purchasing models for provider
reimbursement; paragraph (c)(1)(ii) provides that States have the flexibility to require managed
care plan participation in broad-ranging delivery system reform or performance improvement
initiatives; and paragraph (c)(1)(iii) provides that States may require certain payment levels for
MCOs, PIHPs, and PAHPs to support State practices critical to ensuring timely access to high-
quality care.
Under section 438.6(c)(2), contract arrangements that direct the MCO's, PIHP's, or PAHP's
expenditures under paragraphs (c)(1)(i) through (iii) must have written approval from CMS prior
to implementation and before approval of the corresponding managed care contract(s) and rate
certification(s). This preprint implements the prior approval process and must be completed,
submitted, and approved by CMS before implementing any of the specific payment
arrangements described in section 438.6(c)(1)(i) through (iii).
Standard Questions for All Payment Arrangements
In accordance with §438.6(c)(2)(i), the following questions must be completed.
DATE AND TIMING INFORMATION:
1. Identify the State’s managed care contract rating period for which this payment arrangement
will apply (for example, July 1, 2017 through June 30, 2018):
2. Identify the State’s requested start date for this payment arrangement (for example, January
1, 2018):
3. Identify the State’s expected duration for this payment arrangement (for example, 1 year, 3
years, or 5 years):
Department of Health and Human Services Section 438.6(c) Preprint – 07/31/17
Centers for Medicare & Medicaid Services STATE: ________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #52). The time required to
complete this information collection is estimated to average 1 hour per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
2
STATE DIRECTED VALUE-BASED PURCHASING:
4. In accordance with §438.6(c)(1)(i) and (ii), the State is requiring the MCO, PIHP, or PAHP
to implement value-based purchasing models for provider reimbursement, such as alternative
payment models (APMs), pay for performance arrangements, bundled payments, or other
service payment models intended to recognize value or outcomes over volume of services; or
the State is requiring the MCO, PIHP, or PAHP to participate in a multi-payer or Medicaid-
specific delivery system reform or performance improvement initiative. Check all that
apply; if none are checked, proceed to Question 6.
Quality Payments / Pay for Performance (Category 2 APM, or similar)
Bundled Payments / Episode-Based Payments (Category 3 APM, or similar)
Population-Based Payments / Accountable Care Organization (ACO) (Category 4 APM,
or similar)
Multi-Payer Delivery System Reform
Medicaid-Specific Delivery System Reform
Performance Improvement Initiative
Other Value-Based Purchasing Model
5. Provide a brief summary or description of the required payment arrangement selected above
and describe how the payment arrangement intends to recognize value or outcomes over
volume of services (the State may also provide an attachment). If “other” was checked
above, identify the payment model. If this payment arrangement is designed to be a multi-
year effort, describe how this application’s payment arrangement fits into the larger multi-
year effort. If this is a multi-year effort, identify which year of the effort is addressed in this
application.
Department of Health and Human Services Section 438.6(c) Preprint – 07/31/17
Centers for Medicare & Medicaid Services STATE: ________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #52). The time required to
complete this information collection is estimated to average 1 hour per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
3
STATE DIRECTED FEE SCHEDULES:
6. In accordance with §438.6(c)(1)(iii), the State is requiring the MCO, PIHP, or PAHP to adopt
a minimum or maximum fee schedule for network providers that provide a particular service
under the contract; or the State is requiring the MCO, PIHP, or PAHP to provide a uniform
dollar or percentage increase for network providers that provide a particular service under the
contract. Check all that apply; if none are checked, proceed to Question 10.
Minimum Fee Schedule
Maximum Fee Schedule
Uniform Dollar or Percentage Increase
7. Use the checkboxes below to identify whether the State is proposing to use §438.6(c)(1)(iii)
to establish any of the following fee schedules:
The State is proposing to use an approved State plan fee schedule
The State is proposing to use a Medicare fee schedule
The State is proposing to use an alternative fee schedule established by the State
8. If the State is proposing to use an alternative fee schedule established by the State, provide a
brief summary or description of the required fee schedule and describe how the fee schedule
was developed, including why the fee schedule is appropriate for network providers that
provide a particular service under the contract (the State may also provide an attachment).
9. If using a maximum fee schedule, use the checkbox below to make the following assurance:
In accordance with §438.6(c)(1)(iii)(C), the State has determined that the MCO, PIHP,
or PAHP has retained the ability to reasonably manage risk and has discretion in
accomplishing the goals of the contract.
Department of Health and Human Services Section 438.6(c) Preprint – 07/31/17
Centers for Medicare & Medicaid Services STATE: ________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #52). The time required to
complete this information collection is estimated to average 1 hour per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
4
APPROVAL CRITERIA FOR ALL PAYMENT ARRANGEMENTS:
10. In accordance with §438.6(c)(2)(i)(A), describe in detail how the payment arrangement is
based on the utilization and delivery of services for enrollees covered under the contract (the
State may also provide an attachment).
11. In accordance with §438.6(c)(2)(i)(B), identify the class or classes of providers that will
participate in this payment arrangement.
12. In accordance with §438.6(c)(2)(i)(B), describe how the payment arrangement directs
expenditures equally, using the same terms of performance, for the class or classes of
providers (identified above) providing the service under the contract (the State may also
provide an attachment).
Department of Health and Human Services Section 438.6(c) Preprint – 07/31/17
Centers for Medicare & Medicaid Services STATE: ________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #52). The time required to
complete this information collection is estimated to average 1 hour per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
5
QUALITY CRITERIA AND FRAMEWORK FOR ALL PAYMENT ARRANGEMENTS:
13. Use the checkbox below to make the following assurance (and complete the following
additional questions):
In accordance with §438.6(c)(2)(i)(C), the State expects this payment arrangement to
advance at least one of the goals and objectives in the quality strategy required per §438.340.
a. Hyperlink to State’s quality strategy (consistent with §438.340(d), States must post the
final quality strategy online beginning July 1, 2018; if a hyperlink is not available, please
attach the State’s quality strategy):
b. Date of quality strategy (month, year):
c. In the table below, identify the goal(s) and objective(s) (including page number
references) this payment arrangement is expected to advance:
Table 13(c): Payment Arrangement Quality Strategy Goals and Objectives
Goal(s) Objective(s) Quality
strategy
page
If additional rows are required, please attach.
d. Describe how this payment arrangement is expected to advance the goal(s) and
objective(s) identified in Question 13(c). If this is part of a multi-year effort, describe
this both in terms of this year’s payment arrangement and that of the multi-year payment
arrangement.
Department of Health and Human Services Section 438.6(c) Preprint – 07/31/17
Centers for Medicare & Medicaid Services STATE: ________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #52). The time required to
complete this information collection is estimated to average 1 hour per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
6
14. Use the checkbox below to make the following assurance (and complete the following
additional questions):
In accordance with §438.6(c)(2)(i)(D), the State has an evaluation plan which measures
the degree to which the payment arrangement advances at least one of the goal(s) and
objective(s) in the quality strategy required per §438.340.
a. Describe how and when the State will review progress on the advancement of the State’s
goal(s) and objective(s) in the quality strategy identified in Question 13(c). If this is any
year other than year 1 of a multi-year effort, describe prior year(s) evaluation findings
and the payment arrangement’s impact on the goal(s) and objective(s) in the State’s
quality strategy. If the State has an evaluation plan or design for this payment
arrangement, or evaluation findings or reports, please attach.
b. Indicate if the payment arrangement targets all enrollees or a specific subset of enrollees.
If the payment arrangement targets a specific population, provide a brief description of
the payment arrangement’s target population (for example, demographic information
such as age and gender; clinical information such as most prevalent health conditions;
enrollment size in each of the managed care plans; attribution to each provider; etc.).
Department of Health and Human Services Section 438.6(c) Preprint – 07/31/17
Centers for Medicare & Medicaid Services STATE: ________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #52). The time required to
complete this information collection is estimated to average 1 hour per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
7
c. Describe any planned data or measure stratifications (for example, age, race, or ethnicity)
that will be used to evaluate the payment arrangement.
d. Provide additional criteria (if any) that will be used to measure the success of the
payment arrangement.
REQUIRED ASSURANCES FOR ALL PAYMENT ARRANGEMENTS:
15. Use the checkboxes below to make the following assurances:
In accordance with §438.6(c)(2)(i)(E), the payment arrangement does not condition
network provider participation on the network provider entering into or adhering to
intergovernmental transfer agreements.
In accordance with §438.6(c)(2)(i)(F), the payment arrangement is not renewed
automatically.
In accordance with §438.6(c)(2)(i), the State assures that all expenditures for this
payment arrangement under this section are developed in accordance with §438.4, the
standards specified in §438.5, and generally accepted actuarial principles and practices.
Department of Health and Human Services Section 438.6(c) Preprint – 07/31/17
Centers for Medicare & Medicaid Services STATE: ________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #52). The time required to
complete this information collection is estimated to average 1 hour per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
8
Additional Questions for Value-Based Payment Arrangements
In accordance with §438.6(c)(2)(ii), if a checkbox has been marked for Question 4, the following
questions must also be completed.
APPROVAL CRITERIA FOR VALUE-BASED PAYMENT ARRANGEMENTS:
16. In accordance with §438.6(c)(2)(ii)(A), describe how the payment arrangement makes
participation in the value-based purchasing initiative, delivery system reform, or performance
improvement initiative available, using the same terms of performance, to the class or classes
of providers (identified above) providing services under the contract related to the reform or
improvement initiative (the State may also provide an attachment).
QUALITY CRITERIA AND FRAMEWORK FOR VALUE-BASED PAYMENT
ARRANGEMENTS:
17. Use the checkbox below to make the following assurance (and complete the following
additional questions):
In accordance with §438.6(c)(2)(ii)(B), the payment arrangement makes use of a
common set of performance measures across all of the payers and providers.
a. In the table below, identify the measure(s) that the State will tie to provider performance
under this payment arrangement (provider performance measures). To the extent
practicable, CMS encourages States to utilize existing validated performance measures to
evaluate the payment arrangement.
TABLE 17(a): Payment Arrangement Provider Performance Measures
Provider
Performance
Measure
Number
Measure
Name and
NQF # (if
applicable)
Measure
Steward/
Developer (if
State-developed
measure, list
State name)
State
Baseline
(if available)
VBP
Reporting
Years*
Notes**
1.
2.
3.
Department of Health and Human Services Section 438.6(c) Preprint – 07/31/17
Centers for Medicare & Medicaid Services STATE: ________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #52). The time required to
complete this information collection is estimated to average 1 hour per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
9
Provider
Performance
Measure
Number
Measure
Name and
NQF # (if
applicable)
Measure
Steward/
Developer (if
State-developed
measure, list
State name)
State
Baseline
(if available)
VBP
Reporting
Years*
Notes**
4.
5.
6.
If additional rows are required, please attach.
*If this is planned to be a multi-year payment arrangement, indicate which year(s) of the
payment arrangement the measure will be collected in.
**If the State will deviate from the measure specification, please describe here. Additionally, if a
State-specific measure will be used, please define the numerator and denominator here.
b. Describe the methodology used by the State to set performance targets for each of the
provider performance measures identified in Question 17(a).
REQUIRED ASSURANCES FOR VALUE-BASED PAYMENT ARRANGEMENTS:
18. Use the checkboxes below to make the following assurances:
In accordance with §438.6(c)(2)(ii)(C), the payment arrangement does not set the amount
or frequency of the expenditures.
In accordance with §438.6(c)(2)(ii)(D), the payment arrangement does not allow the
State to recoup any unspent funds allocated for these arrangements from the MCO, PIHP, or
PAHP.
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