Crosswalk - Section 438.6(c) Preprint

2017 (old version)	2020 (new version)	Type of Change	Reason for Change	Burden Change
	Added State Directed Payment Identifier	Add	Added as part of process to better track state directed payment arrangements over time. CMS will assign the identifier and ask states to use it in all submissions and related actions (contracts and rates)	Yes - minor addition of burden to this process. However, the addition here is intended to save time and effort during subsequent contract and rate reviews.
Intro Section - "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)."	Intro Section - "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. 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)."	Rev	Shortened for ease.	No
Question 1, "for example, July 1, 2017 through June 30, 2018)"	Question 1, "for example, July 1, 2020 through June 30, 2021)"	Rev	Updated to reflect passage of time	No
Question 3: Identify the State's expected duration for this payment arrangement (for example, 1 year, 3 years, or 5 years):	Eliminated	Del	Question proved confusing and provided information that was not useful.	Yes - reduction
	New Question 3 added, "Identify the managed care program(s) for which this payment arrangement will apply:"	Add	Question added to identify the programs affected by the state directed payment. This will facilitate subsequent contract and rate reviews.	Yes - minor addition of burden to this process. However, the addition here is intended to save time and effort during subsequent contract and rate reviews.
	New Question 4 added, "Is this the first year the state is seeking approval under 438.6(c) for this state directed payment arrangement?" with sub questions, "If not the first year, please indicate the periods for which previous approvals have been granted." "Is this an amendment to a currently-approved state directed payment arrangement?" "If not the first year, please note if there is a change in this state directed payment and if the change is to the payment structure, provider class, or another change."	Add	Added as part of process to better track state directed payment arrangements over time. CMS will assign the identifier and ask states to use it in all submissions and related actions (contracts and rates)	Yes - additional information being requested to improve tracking over time. However, the addition here is intended to save time and effort during subsequent contract and rate reviews and save time during the review process.
Question 15, "In accordance with §438.6(c)(2)(i)(F), the payment arrangement is not renewed automatically."	Question 5, "Please use the checkbox to provide an assurance that, in accordance with §438.6(c)(2)(i)(F), the payment arrangement is not renewed automatically."	Rev	This questions was slightly revised for clarity. It was also moved up in the form to improve flow.	No
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."	Question 6, "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). The state should specifically discuss what must occur in order for the provider to receive the payment (e.g., utilization of services by managed care enrollees, meet or exceed a performance benchmark on provider quality metrics)."	Rev	Question was revised to ensure this information is captured in the preprint form (as opposed to an attachment.) Additionally, the revisions to the question are intended to clarify the information CMS is seeking.	No
	New Question 6a, "In cases where the state directed payment is tied to utilization of services under the contract, denote the Medicaid authority for the applicable services (e.g., State Plan, 1115 waiver). Please also submit the authority document."	Add	Question added to collect additional information. It is also intended to clarify for states that the state directed payment is not providing authority to cover services (the state must obtain this authority separately.)	Yes - minor. Addition is to ensure the state has all proper authorities in place for the state directed payment arrangement.
	New Question 7, "Please select the general type of state directed payment arrangement the state is seeking prior approval to implement. (Check all that apply and address the underlying questions for each category selected.)" VALUE-BASED PAYMENTS / DELIVERY SYSTEM REFORM: 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. If checked, please answer all questions in Subsection IIA. FEE SCHEDULE REQUIREMENTS: 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. [Please note, per the 2020 Medicaid and CHIP final rule, states no longer need to submit a preprint for prior approval for minimum fee schedule directed payments that utilize a State Plan approved fee schedule to be implemented.] If checked, please answer all questions in Subsection IIB.	Add	Question was added to improve information collection and provide clearer directions for states on which questions need to be completed depending on the type of payment arrangement. Language for Value-Based Payments/ Delivery System Reform was largely lifted from the original preprint Question 4. Language for the Fee Schedule Requirements was largely lifted from the original preprint Question 6.	Yes - minor. The state will be asked to response by checking a box, but this change is intended to facilitate clearer instructions on the information needed depending on the type of state directed payment.
Question 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 Payment/ Pay for Performance (Category 2 APM, or similar) - Bundled Payment/Episode-Based Payments (Category 3 APM, or similar) - Population-Based Payment/Accountable Care Organization (Category 4 APM, or similar) - Multi-Payer Delivery System Reform - Medicaid-Specific Delivery System Reform - Performance Improvement Initiative - Other Value-Based Purchasing Model"	Question 8, "Please check the type of VBP/DSR state directed payment the state is seeking prior to approval for. Check all that apply; if none are checked, proceed to Section III. - Quality Payment/ Pay for Performance (Category 2 APM, or similar) - Bundled Payment/Episode-Based Payments (Category 3 APM, or similar) - Population-Based Payment/Accountable Care Organization (Category 4 APM, or similar) - Multi-Payer Delivery System Reform - Medicaid-Specific Delivery System Reform - Performance Improvement Initiative - Other Value-Based Purchasing Model"	Rev	Question was revised in light of the new Question 7. Otherwise, this question is nearly identical to the old Question 4. List of VBP/DSR types is the same.	No
Question 5, "9. 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."	Question 9, "9. 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. If “other” was checked above, identify the payment model. The state should specifically discuss what must occur in order for the provider to receive the payment (e.g., meet or exceed a performance benchmark on provider quality metrics)."	Rev	Question was revised to ensure this information is captured in the preprint form (as opposed to an attachment.) Additionally, the revisions to the question are intended to clarify the information CMS is seeking.	No
Question 10, "In the table below, identify the measure(s) 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) captures Provider Performance Measure Number, the Measure Name and NQF# (if applicable), Measure Steward/Developer *of State-Developed measure, list State name), State Baseline (if applicable), VBP Reporting Years, and Notes. Additional footnotes are added: - 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.	Question 10, "In Table 1 below, identify the measure(s), baseline statistics, and targets that the State will tie to provider performance under this payment arrangement (provider performance measures). Please complete all boxes in the row. To the extent practicable, CMS encourages States to utilize existing validated performance measures to evaluate the payment arrangement, and recommends states use the CMS Adult and Child Core Set Measures when applicable. Table 1 captures the Name and NQF# (if applicable), Steward/Developer, Baseline Year and Baseline Statistic, Performance Measurement Period and Performance Target, and Notes. An example is provided. Additional footnotes are added: 1. If state-developed, list State name as Steward Developer. 2. Baseline data must be added after the first year of the payment arrangement. 3. If this is planned to be a multi-year payment arrangement, indicate which year(s) of the payment arrangement that performance on the measure will trigger payment. 4. If the State is using an established measure and will deviate from the measure steward's measure specifications, please describe here (Notes). Additionally, if a State-specific measure will be used, please define the numerator and denominator here (Notes).	Rev	Question was revised to ensure this information is captured in the preprint form (as opposed to an attachment.) Additionally, the revisions to the question are intended to clarify the information CMS is seeking and emphasize CMS' preference for using Core Set measures.	Yes - minor addition of burden to this process. However, this is generally collected during preprint review now as part of questions and responses.
Question 17b, "Describe the methodology used by the State to set performance targets for each of the provider performance measures identified in Question 17(a)."		Del	Question did not yield necessary information.	Yes - reduction
	New Question 11, "For the measures listed in Table 1 above, please provide the following information: a. If multiple provider performance measures are involved in the payment arrangement, discuss if the provider must meet the performance target on each measure to receive payment or can providers receive a portion of the payment if they meet the performance target on some but not all measures? b. For state-developed measures, please briefly describe how the measure was developed?	Add	Question was revised to ensure this information is captured in the preprint form (as opposed to an attachment.) Additionally, the revisions to the question are intended to clarify the information CMS is seeking.	Yes - minor addition of burden to this process. However, the addition here is intended to save time and effort during both the preprint review and subsequent contract and rate reviews.
	New Question 12, "Is the state seeking a multi-year approval of the state-directed payment arrangement? a. If this payment arrangement is designed to be a multi-year effort, denote the State’s managed care contract rating period(s) the state is seeking approval for. b. If this payment arrangement is designed to be a multi-year effort and the state is NOT requesting a multi-year approval, describe how this application’s payment arrangement fits into the larger multi-year effort and identify which year of the effort is addressed in this application. "	Add	This question was added in light of regulatory changes. CMS is finalizing regulations that would allow for multi-year approvals for VBP/DSR arrangements only.	Yes - reduction; states will be able to clearly request approval for multiple years for select payment arrangements instead of annually, reducing paperwork.
Question 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." Question 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." Question 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."	13. Use the checkboxes below to make the following assurances: a. In accordance with §438.6(c)(2)(ii)(A), the state-directed 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 below) providing services under the contract related to the reform or improvement initiative. b. 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. c. 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.	Rev	This question was revised to collect all the assurances previously asked for in 1 place that are specific to VBP arrangements. The assurances in b-d are the same as before; nothing was edited. The first assurance was created based on Question 16 of the original preprint; it was revamped into an assurance given the increased number of questions for VBP arrangements.	No
Question 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"	Question 14, "Please check the type of state-directed payment the state is seeking prior approval for. Please note, per the 2020 Medicaid and CHIP final rule, states no longer need to submit a preprint for prior approval for minimum fee schedule directed payments that utilize a State Plan approved fee schedule to be implemented. Check all that apply; if none are checked, proceed to Section III. a. Minimum Fee Schedule for providers that provide a particular service under the contract using rates other than state plan approved rates (438.6(c)(1)(iii)(B)) b. Other Fee Schedule (438.6(c)(1)(iii)(E)) c. Maximum Fee Schedule (438.6(c)(1)(iii)(D)) d. Uniform Dollar or Percentage Increase (438.6(c)(1)(iii)(C)) If 14a-c are checked, please respond to Question 15. If 14d is checked, please respond to question 16.	Rev	Question was revised in light of the new Question 7 and regulatory changes the agency is finalizing (e.g. no longer requiring prior approval of minimum fee schedules that utilize a state plan approved fee schedule).	No
Question 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" Question 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)."	Question 15, "If the state is seeking prior approval of a fee schedule (options a-c in Question 13), please check the basis for the fee schedule selected above. a. The State is proposing to use a fee schedule based on a state-plan approved rates as defined in 438.6(a). b. The State is proposing to use a fee schedule based on a Medicare or Medicare-equivalent rate c. The State is proposing to use a fee schedule based on an alternative fee schedule established by the State. i. If the state is proposing an alternative fee schedule, please describe what the alternative fee schedule is (e.g. % of Medicaid state-plan approved rate) and how the alternative fee schedule was established and why it is appropriate."	Rev	Questions 7 and 8 from the original preprint were revised. The new Question 15 focuses only on state directed payments that are fee schedules (Min, Max or other) while a separate question (Question 16) focuses on uniform increases.	No
	Question 16, "If the State is seeking prior approval for a uniform dollar or percentage increase (option d in Question 14), please address the following questions: a. Please provide a brief summary or description of the required increase, including if it is a uniform dollar amount or a uniform % increase, the magnitude of the increase (e.g. $4 per claim or 3% increase per claim) and how it will be paid out (e.g. upon processing the initial claim, a retroactive adjustment done one month after the end of quarter for those claims incurred during that quarter). b. Describe how the increase was developed, including why the increase is appropriate for network providers that provide a particular service under the contract."	Add	This question was added to focus specifically on state directed payments that are uniform increases. In the old form, states were confused about what information to include where for uniform increases.	No
Question 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."	Question 17, "If using a maximum fee schedule (option b in Question 14), please answer the following additional questions: a. Please use the checkbox to provide 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. b. Please describe the process for plans and providers to request an exemption if they are under contract obligations that result in the need to pay more than the maximum fee schedule. Please also indicate your expectations in terms of the number of exemptions to the requirement expected as well as the number of exemptions granted in past years of this payment arrangement and how such exemptions will be considered in rate development.	Rev	Additional information is being requested about the exemption process the state uses to ensure that the maximum fee schedule does not prevent the plan from meeting its requirements to ensure access to care. This information currently is asked for as part of the review process for max fee schedules currently; CMS is seeking to add it to the form so that this information is more consistently captured.	No
Question 11, "In accordance with §438.6(c)(2)(i)(B), identify the class or classes of providers that will participate in this payment arrangement."	Question 18, "In accordance with §438.6(c)(2)(i)(B), identify the class or classes of providers that will participate in this payment arrangement. a. Please indicate which general class of providers would be affected by the state-directed payment (check all that apply): - inpatient hospital services - outpatient hospital services - professional services at an academic medical center - primary care services - specialty care services - nursing facility services - HCBS/personal care services - behavioral health inpatient services - behavioral health outpatient services - dental services - Other: b. Please define the provider class(es) (if further narrowed from the general classes indicated above.) Please also denote if the provider class is defined in the State Plan and attach the applicable State Plan pages to the preprint submission. If not defined in the State Plan, please provide a justification for the provider class.	Rev	This question was revised to collect more consistent information across preprints about the types of provider classes involved in state directed payments. If the class is based on something defined in the state plan, states are also asked to submit the appropriate documentation.	Yes - minor addition of burden to submit the state plan pages if the provider class is defined in the state plan. This will assist in ensuring CMS has all the appropriate documentation.
Question 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)."	Question 19, "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."	Rev	Question was revised to ensure this information is captured in the preprint form (as opposed to an attachment.)	No
	Question 20, "For the services impacted by the state directed payment, how will the state directed payment interact with the negotiated rate(s) between the plan and the provider? Will the state directed payment: - Replace the negotiated rate(s) between the plan(s) and provider(s) - Limit but not replace the negotiated rate(s) between the plans(s) and provider(s) - Require a payment be made in addition to the negotiated rate(s) between the plan(s) and provider(s) Question 21, "For payment arrangements that are intended to require plans to make a payment in addition to the negotiated rates, please provide an analysis showing the impact of the state directed payment on payment levels for each provider class. This should include an estimate of the base reimbursement rate the managed care plans pay to these providers as a percent of Medicare, or some other standardized measure, and the effect the increase from the directed payment will have on total payment (e.g., Base payment rate is x% of Medicare and this directed payment is expected to increase reimbursement to y% of Medicare). Table 2 asks for the provider class(es); the average base payment level; the effect on total payment level of the state directed payment, other state directed payments and pass-through payments; total payment level." Question 22, "Please describe the data sources and methodology used for the analysis provided in response to Question 21." Question 23, "Please describe the state's process for determining how the proposed state-directed payment was appropriate and reasonable."	Add	Questions were added to obtain information from states asked during review more formally in the preprint form itself. The question also help to clarify the information CMS needs for these reviews.	Yes - additional information being requested as part of the preprint form instead of through follow-up questions and responses.
	Question 24, "Has the actuarial certification for the rating period for which this state directed payment applies been submitted to CMS? a. What is the control name(s) of the rate review(s) provided by CMS?" Question 25, "If the state has submitted the actuarial certification for the rating period for which this state directed payment applies, does the certification(s) incorporate this state directed payment? a. If yes, please indicate where the state directed payment is captured in the rate certification(s). (Please note, states and actuaries should consult the most recent Medicaid Managed Care Rate Guide for how to document state directed payments in rate certifications.)" Question 26, "If the state directed payment is expected to result in additional dollars being added to the rate certification, detail the total dollars (federal and non-federal dollars) being added for this state directed payment by rate certification/program. If the state is also including any sub-pools, please denote the total dollars per sub-pools as well." Question 27, "Describe how the state will/has incorporate this state directed payment arrangement in the applicable rate certification (e.g., an adjustment applied in the development of the monthly base capitation rates for which the managed care plans are at-risk, separate payment term)." Question 28, "For state directed payment(s) incorporated into the applicable rate certification(s) as a separate payment term, provide additional justification as to why this is necessary (as opposed to incorporating as an adjustment applied to the development of the monthly base capitation rates or which managed care plans are at-risk."	Add	Questions are being added to more consistently capture information necessary for related rate and contract reviews. Question 25a also provides states with guidance on what documentation is needed in subsequent rate certification reviews.	Yes - additional burden added. However, states are asked many of these questions under the current review process. Additionally, capturing this information up front is expected to facilitate related contract and rate reviews.
Question 15, "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."	Question 29, "Please use the checkbox to provide the following assurance: 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."	Rev	Question revised to provide additional clarity.	No
	Question 30, "Describe the non-federal share of the payment arrangement, including the source for the non-federal share (e.g., state legislative appropriations to the Medicaid agency, intergovernmental transfers (from a state or local government entity), provider taxes)." Question 31, "For any payment funded by IGTs, please provide the following: a. A complete list of the names of entities transferring funds b. The operational nature of the entity (state, county, city, other) c. The total amounts transferred by each entity d. Clarify whether the transferring entity has general taxing authority e. Whether the transferring entity received appropriations (identify level of appropriations) f. Information or documentation regarding any written agreements that exist between the state and healthcare providers or amongst healthcare providers and/or related entities relating to the non-federal share of the payment arrangement. This should include any additional written agreements that may exist with healthcare providers to support and finance the non-federal share of the payment arrangement."	Add	Questions were added to obtain information from states asked during review more formally in the preprint form itself.	Yes - additional burden added. However, states are asked these questions under the current review process.
Question 15, "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."	Question 32, "Please use the checkbox to provide an assurance that 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."	Rev	Question was revised from original preprint to capture the same assurance in the section of the new preprint related to the source of non-federal share. The assurance language has not changed.	No
Question 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) captured the Goal(s), Objective(s) and Quality Strategy page. 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."	Question 33, "Use the checkbox below to make the following assurance, “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.”" Question 34, "Please provide a hyperlink to State’s most recent 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:" Question 35, "Please provide the effective date of quality strategy. If the state is currently updating the quality strategy, provide a target date for submission of the revised quality strategy, attach a draft version, and note any potential changes that might be made to the goals and objectives. The state should submit the final version to CMS as soon as it is finalized. To be in compliance with § 438.340(c)(2) the quality strategy must be updated no less than once every 3-years. (month, year):" Question 36, "To obtain written approval of this payment arrangement, a state must demonstrate that each directed payment arrangement expects to advance at least one of the goals and objectives in the quality strategy. In the table 3 below, identify the goal(s) and objective(s), as they appear in the Quality Strategy (include page numbers), this payment arrangement is expected to advance. If additional rows are required, please attach. Table 3 captures information on the Goal(s), Objective(s) and Quality strategy page. Question 37, "37. Describe how this payment arrangement is expected to advance the goal(s) and objective(s) identified in Table 3. 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. "	Rev	Questions were revised mostly to break out into separate questions (rather than sub questions.) Additional information on regulatory requirements that have now taken effect since the original preprint was published are noted in Questions 34 and 35 of the revised preprint. Question 36 more clearly articulates the regulatory requirement related to collecting this information; the table also provides an example to clarify the information CMS is requesting. otherwise the questions	No
Question 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.). 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."	Question 38, "Please complete the following questions regarding having an evaluation plan to measure the degree to which the payment arrangement advances at least one of the goals and objectives of the State’s quality strategy. To the extent practicable, CMS encourages States to utilize existing validated performance measures to evaluate the payment arrangement, and recommends states use the CMS Adult and Child Core Set Measures, when applicable. a. In accordance with §438.6(c)(2)(i)(D), use the checkbox to assure the State has an evaluation plan which measures the degree to which the payment arrangement advances at least one of the goals and objectives in the quality strategy required per §438.340, and that the evaluation conducted will be specific to this payment arrangement. (States have flexibility in how the evaluation is conducted and may leverage existing resources, such as their 1115 demonstration evaluation if this payment arrangement is tied to an 1115 demonstration or their External Quality Review validation activities, as long as those evaluation or validation activities are specific to this payment arrangement and its impacts on health care quality and outcomes). b. 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 33(b). For each measure the state intends to use in the evaluation of this payment arrangement, provide in the table below: 1) the baseline year, 2) the baseline statistics, and 3) the performance targets the state will use to track the impact of this payment arrangement on the state’s goals and objectives. If the State has an evaluation plan or design for this payment arrangement, please attach." Table 4 captures Measure Name and NQF # (if applicable), Baseline Year, Baseline Statistic, Performance Target, and Notes. Table includes a footnote on the Notes column, "If the State will deviate from the measure specification, please describe here. If a State-specific measure will be used, please define the numerator and denominator here. Additionally, describe any planned data or measure stratifications (for example, age, race, or ethnicity) that will be used to evaluate the payment arrangement. " "c. If this is any year other than year 1 of a multi-year effort, describe (or attach) prior year(s) evaluation findings and the payment arrangement’s impact on the goal(s) and objective(s) in the State’s quality strategy. Evaluation findings must include 1) historical data; 2) prior year result data; and 3) a description of the evaluation methodology. The State is also encouraged to confirm baseline and performance target information from the prior preprint. If full year 1 findings are not available, provide partial year findings and an anticipated date for when CMS may expect to receive the full year 1 findings."	Rev	Question was revised to clarify that the evaluation needs to be specific to the payment arrangement and to more clearly capture information CMS asks for during review in line with guidance published in November 2017 - specifically, the measure name, baseline year, the baseline statistic, and the performance target. Specifically, the assurance was revised to be more specific from the assurance language included previously. Question 14a of the original preprint was broken out into the new Question 38b and 38c. Question 38b clarifies the details CMS expects for a state evaluation plan and are regularly asked for as part of ongoing reviews; inclusion in the preprint will streamline collection to capture information more consistently across states. Question 38c also clarifies CMS' expectation for states to include evaluation results from previous years as well as what additional information should be included in the evaluation results. Question 38c also denotes what information states should provide if year 1 results are not available at the time of submission (partial year findings and anticipated date for when CMS expects to receive fully year 1 findings.)	Yes - additional burden being added as state will be asked to provide this information up front in the preprint form. However, states are currently asked for this information during preprint reviews currently.
PRA Disclosure Statement: "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."	PRA Disclosure Statement This form is used by states to obtain approval of state directed payments (payment arrangements that states contractually require their plans to implement for covered services under the contract) as required under 42 CFR 438.6(c). The use of this form is mandatory under the authority of Section 1903(b) of the Social Security Act and 42 CFR 438.6(c). Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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 1.5 hours 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.	Rev	PRA disclosure statement was updated to include purpose of the PRA package. Time to complete the form was also updated to reflect revisions. Per guidance, the PRA disclosure statement is only included on the first page (previously was on every page.)	No