MEDICAID MANAGED CARE: SUPPLEMENTAL PAYMENTS
Medicaid Managed Care: Supplemental Payments
Eyman Associates’ attorneys have a long and successful track record in assisting clients in developing, implementing, financing and defending various Medicaid funding programs, including waiver-based payment mechanisms (such as uncompensated care pools and delivery system reform incentive pools), disproportionate share hospital (DSH) and upper payment limit (UPL) programs, graduate medical education (GME) payments, and supplemental physician payments.
Much of our recent work has been focused on ensuring adequate funding in managed care delivery systems. Eyman Associates has been on the forefront of this work since CMS overhauled its Medicaid managed care regulations in 2016, providing new authorities for states to direct payments to providers when certain conditions are met. States have begun to implement a wide variety of programs under these new authorities, codified at 42 CFR §438.6(c), and CMS is rapidly developing standardized (but partially unwritten) policies to govern them. Through these CMS-approved programs, states can direct managed care organizations to adopt specific provider payment policies, arrangements and rates. The programs can include rate increases and minimum or maximum fee schedules, as well as delivery system reform programs and value-based payment programs. CMS has developed a separate process for states to propose these payments (through a federally-developed “preprint”), which then must also be incorporated into the state’s managed care contracts and rates. We have unique insight into CMS’ policies in this area obtained through a series of Freedom of Information Act requests to CMS, through which we have assembled and analyzed a comprehensive database of managed care directed payment programs across the country.
As these directed payments have been implemented nationwide, CMS has signaled a desire to review this authority and potentially issue rulemaking. We are closely following all developments in this area to provide our clients with the most accurate and up to date opportunities for funding through managed care. Refer below to the latest updates and most relevant resources on Directed Payments.
CMS Proposes Changes to Medicaid Managed Care Rules, Including on State Directed Payments
On Thursday, April 27, the Centers for Medicare & Medicaid Services (CMS) issued a long-anticipated proposed rule related to Medicaid and CHIP managed care programs. Of particular importance for many of our clients across the country, CMS continued its practice of...
MACPAC, GAO Recommend Oversight Changes for Managed Care Directed Payments
Both The Medicaid and CHIP Access and Payment Commission and the Government Accountability Office have recently published recommendations for increasing transparency of managed care directed payment programs to facilitate closer evaluation of direct payment programs....
CMS Approves California Advancing & Innovating Medi-Cal (CalAIM) Waivers, Including Provisions to Address Social Determinants of Health
In December, CMS approved some of California’s CalAim proposals through extensions of its 1115 demonstration and 1915(b) managed care waivers. California is transitioning significant programs under its prior 1115 waiver into its 1915(b) waiver, and working to sustain...
Critical Guidance & Preprint Application Forms
- State Medicaid Director Letter on Managed Care Directed Payments (Jan. 2021)
- Revised Directed Payment Preprint Application (Jan. 2021)
- State Medicaid Director Letter on New Managed Care Directed Payment Opportunities (Nov. 2017)
- Original Directed payment Preprint Application (Nov. 2017)
- CMS Medicaid Managed Care Rate Development Guide, 2020-21 (Updated Annually here)
- CMS Informational Bulletin on Pass Through Payments (July 2016)
Rulemaking on Medicaid Managed Care
- 2020 Final Rule on Medicaid Managed Care (Nov 2020)
- 2018 Proposed Rule (Nov 2018)
- 2017 Final Rule on Pass Through Payments (Jan 2017)
- 2016 Proposed Rule (Nov 2016)
- 2016 Final Rule on Medicaid Managed Care (May 2016)
- 2015 Proposed Rule (June 2015)