Read this if you are at a State Medicaid Agency (SMA).
On April 27, 2023, the Centers for Medicare & Medicaid Services (CMS) published a proposed new rule titled “Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality” intended to address the most critical elements of access and person-centered care. As part of these proposed changes, CMS proposed significant updates around rules and guidelines for State Directed Payments (SDPs). Below is a summary of proposed SDP updates for which CMS is seeking feedback.
Evaluation plan
CMS is proposing that states be required to submit written evaluation plans for SDPs every three years if a respective SDP program exceeds 1.5% of overall capitation payments.
Medical Loss Ratio
One of the most significant changes proposed by CMS is the requirement that all SDPs be included in Medical Loss Ratio (MLR) calculations by Medicaid managed care plans. This represents a departure from past formal or informal guidance explicitly excluding these payments from MLRs. It may present challenges to states because of the mandatory and focused nature of SDPs and their use to solve public health challenges in real-time.
Approval and renewal time frames
Similar to the current process, approval for SDPs is for one rating period unless a multiyear approval of up to three rating periods is requested and meets the criteria. SDPs are not automatically renewed.
CMS report submission
On the data front, CMS is proposing that states be required to submit financial data on SDPs, including total dollars expended. This may provide data that would allow more robust understanding of Medicaid, Medicare, and commercial payment levels that could inform future discussions around allowable methodologies and logic for calculating SDP rate ceilings.
SDP amendment and removal of prior-approval requirements for some SDPs
States wanting to amend SDPs after receiving CMS approval must obtain written prior approval for the amendments, unless the SDPs are based on State Plan Amendment (SPA)-approved rates per the amended 2020 rule. CMS is now proposing to expand this prior-approval requirement to SDP programs based on a minimum fee schedule methodology using Medicare-approved rates. This proposal may significantly reduce the administrative burden to states and providers.
SDP actuarial implications
CMS has indicated that they prefer that SDPs be included as adjustments to the capitation rates, but CMS recognizes the need for state flexibility. Separate payments must be certified by the state, through its actuary, and the separate payment must be included in the rate certification. SDP payments must be based on the delivery of services in the rating period and not on a historical basis, although they may be estimated using historical data. CMS proposes to assess all SDP payments in aggregate in a managed care program to ensure they are reasonable, appropriate, and obtainable. There are also implications for value-based payments (VBP) SDP initiatives that actuaries working for the state should consider, such as removing the requirements that prohibit states from recouping unspent funds.
Feedback requested
CMS is seeking feedback on these proposed rules. Public comments are due by July 3, 2023, and can be submitted at the following link: Regulations.gov.
If you would like more information, have questions about the proposed rule, or need assistance in assessing, developing, or implementing these or other changes to your state managed care program, please contact our Medicaid consulting team. We’re here to help.