State Directed Payment Programs

The 2016 Medicaid managed care rule created a new option for states to require managed care plans to pay providers according to specific rates or methods, referred to as state directed payments. To better serve the citizens of Georgia, these types of payment arrangements allow Georgia to direct specific payments made by managed care plans to providers.

Older doctor on computer looking interested in what is on the screen.

The Centers for Medicare & Medicaid Services (CMS) Medicaid managed care regulations at 42 C.F.R. Part 438 govern how states may direct plan expenditures in connection with implementing delivery system and provider payment initiatives under Medicaid managed care contracts, including those with managed care organizations (MCOs), prepaid inpatient health plans (PIHPs), and prepaid ambulatory health plans (PAHPs), herein referred to as managed care plans.

By way of a CMS Preprint, Georgia has implemented the programs outlined below. Pending programs are currently under federal review and are subject to modifications based on CMS guidance. Please consider uploaded preprint as a draft version, until DCH uploads final CMS approval letter.

Approved FY 2022 DPPs (FY 2023 still pending)

None at this time.

Approved FY 2023 DPPs

Physician Directed Payment Program (PDPP)

Georgia’s PDPP provides state directed payments to eligible physicians and other professional services practitioners who are affiliated with a governmental teaching hospital. Medicaid Care Management organizations (CMOs) will pay directed payments for services provided at a physician faculty practice up to the commercial equivalent.    

Participation in the program is voluntary and the source of non-federal funds is provided by the hospital authority or governmental entity on behalf of the eligible provider through an intergovernmental transfer (IGT) to the Georgia Department of Community Health (DCH). 

Key Elements of PDPP

  • Payment structure: Uniform increase up to Commercial equivalent
  • SFY22 estimate: $115.9M total ($81.1M federal funds, $34.8M non-federal)
  • Approved and evaluated annually by CMS
  • Reconciliation to ensure payments based on actual Medicaid utilization
  • Annually evaluated by State to determine extent to which supports state quality strategy

Hospital Directed Payment Program (HDPP) for Public Hospitals

Georgia’s HDPP provides additional Medicaid funding for eligible participating Public Hospitals. Public hospitals are defined as all state and non-state government hospitals, excluding Critical Access Hospitals (CAHs). This program is estimated to increase provider funding of critical services for the Medicaid population and strengthen Georgia’s healthcare workforce.

Under the program, eligible participating public hospitals through the Medicaid CMOs will receive increased Medicaid funding via direct payment up to the Medicare equivalent. 

Participation in the program is voluntary and the source of non-federal funds is provided by the hospital authority or governmental entity on behalf of the eligible provider through an IGT to DCH.

Key Elements of HDPP

  • Payment structure: Uniform increase up to Medicare equivalent
  • SFY22 estimate: $188.3M total ($131.8M federal funds, $56.5M non-federal)
  • Approved and evaluated annually by CMS
  • Reconciliation to ensure payments based on actual Medicaid utilization
  • Annually evaluated by State to determine extent to which supports state quality strategy

Georgia’s Advancing Innovation to Deliver Equity (GA-AIDE)

The GA-AIDE program authorizes state directed payments to improve quality of care and outcomes for patients served by Georgia’s largest single provider of Medicaid services, Grady Memorial, and Georgia’s state-owned Academic Medical Center, Augusta University Medical Center. The directed payments fund investments in initiatives designed to improve health outcomes and experiences for the medically underserved. Participation in the program is voluntary and the source of non-federal funds is provided by the hospital authority or governmental entity on behalf of the eligible provider through an IGT to DCH.

Core quality areas of focus will be:

  • Improving maternal and child health
  • Preventing and reducing the impact of chronic conditions
  • Improving access to screening and prevention services 
  • Addressing health equity

Key Elements of GA-AIDE

  • Multi-year, value-based program, approved and evaluated annually by CMS
  • Payment structure:  Uniform increase up to commercial equivalent, with 10% at risk based on meeting defined targets on quality measures
  • Reconciliation to ensure payments based on actual Medicaid utilization
  • SFY23 estimate:  $344.6M total ($228.2M federal funds, $116.4M non-federal)
  • Measures the impact of initiatives on health inequities, providing a model for DCH to measure improvement statewide

New FY 2023 DPPs Under Review

Strengthening The Reinvestment of a Necessary-workforce in Georgia (GA-STRONG)

GA-STRONG is designed to address Georgia’s healthcare workforce shortage through increased funding for hospitals on the front lines of workforce development, which will initially include 21 eligible teaching hospital participants with at least five full-time equivalent residents. The program will allow eligible providers to receive STRONG payments from CMOs based on a uniform percentage increase to base rates of ~50% of the average commercial equivalent. An increase in the current statewide hospital assessment and intergovernmental transfers (IGTs) from participating public teaching hospitals will be used to finance the program’s non-federal share required.

GA-STRONG provides foundational support to the Georgia’s teaching hospitals that are central to healthcare workforce redevelopment. The funds delivered through the program will allow these institutions to build on and expand innovative programs specific to their communities - leading to stabilization, development, and diversification of the healthcare workforce and ultimately improve patient outcomes and advance Georgia’s quality goals.  As such, core quality areas of focus will be statewide improvements through:

  • Workforce retention and growth across the spectrum of care
  • Incentivizing/prioritizing direct patient care
  • Geographic Shortage Areas
  • Accountability via robust hospital specific reporting

Key Elements of STRONG

  • Multi-year program, approved and evaluated annually by CMS
  • Payment structure:  uniform increase payments representing ~50% of commercial equivalent
  • Reconciliation to ensure payments based on actual Medicaid utilization
  • SFY23 estimate:  $746M in total ($494M federal funds, $252M non-federal)

Pending programs are currently under federal review and are subject to modifications based on CMS guidance. Please consider uploaded preprint as a draft version, until DCH uploads final CMS approval letter.

Hospital Directed Payment Program (HDPP) for Private Hospitals

Georgia’s HDPP provides additional Medicaid funding for eligible participating Private Hospitals. Eligible private hospitals are defined as all private, acute hospitals excluding general cancer hospitals, free-standing children's hospitals, and rehabilitative/psychiatric/long term acute hospitals. All Critical Access Hospitals (CAHs) are excluded. This program is estimated to increase provider funding of critical services for the Medicaid population and strengthen Georgia’s healthcare workforce.

Under the program, eligible participating private hospitals through the Medicaid CMOs will receive increased Medicaid funding via direct payment up to the Medicare equivalent. 

Key Elements of HDPP

  • Payment structure:  Uniform increase up to Medicare equivalent
  • SFY23 estimate:  $153.2M total ($101.5M federal funds, $51.7M non-federal)
  • Approved and evaluated annually by CMS
  • Reconciliation to ensure payments based on actual Medicaid utilization
  • Annually evaluated by State to determine extent to which supports state quality strategy

Pending programs are currently under federal review and are subject to modifications based on CMS guidance. Please consider uploaded preprint as a draft version, until DCH uploads final CMS approval letter.

 

Physician DPP ACR Data Request Training 1.5.2023 - Posted 01/13/23

Physician DPP ACR Data Request Training 12.15.2022 - Posted 01/13/23