Aligning Payers and Practices to Transform Primary Care: A Report From the Multi-State Collaborative (August 2014 52 pages)Author is Lisa Dulsky Watkins, MD

We are learning two things about restructuring health care in the United States in the post-Affordable Care Act (ACA) environment: Primary care transformation is essential to a well-performing health care delivery system and payment reform works best when it is consistent across payers.

These things are easier said than done, but the evidence and experience indicate they are possible. A Milbank Memorial Fund report, “Aligning Payers and Practices to Transform Primary Care: A Report from the Multi-State Collaborative,” describes the efforts in states to take on these challenges.

The report details the experiences of the Multi-State Collaborative (MC), a voluntary group composed of representatives of state-based, multi-payer primary care transformation initiatives that are themselves collaborations between payers, providers, employers and state officials. With support from the Milbank Memorial Fund since 2009, the MC has provided a forum for member states to share data, participate in collaborative learning, and advocate for improved collaboration between the states and the federal government on primary care transformation. The report, which is based on a 2013 observational survey of the MC states and interviews with their leaders, looks at the similarities and differences in the activities of each state.

The implementation of the ACA may have focused much attention on insurance provisions, but the real challenges and opportunities for health reform lie in improving the performance of the medical care delivery system. The lessons learned here have implications not only for primary care transformation, but also for state-convened provider payment reform initiatives and any effort at health care transformation requiring alignment across multiple payers.


Harvard  Law School-Center for Health Policy and Innovation

Affordable Care Act : Opportunities for Community Health Workers
How Medicaid Preventive Services, Medicaid Health Homes, and State Innovation Models are 
Including Community Health Workers by Amy Katzen and Maggie Morgan 5/30/2014 (25 pgs)

“The Affordable Care Act has greatly enhanced the role of community health workers in state
Medicaid plans. This has primarily occurred as states have included CHWs in the care teams
described in their Health Home and State Innovation Model plans. States have yet to take
advantage of the new regulation allowing CHWs and other non-licensed providers to provide
preventive health services in Medicaid, but with encouragement from state CHW organizations, it is likely that states will explore this new option.”

The Affordable Care Act’s Prevention and Public Health Fund 

The Affordable Care Act, the health care law of 2010, created a Prevention and Public Health Fund. The fund is an unprecedented investment in promoting wellness, preventing disease, and protecting against public health emergencies.

Much of this work is done in partnership with states and communities, which are already using Prevention Fund dollars to help control the obesity epidemic, fight health disparities, detect and quickly respond to health threats, reduce tobacco use, train the nation’s public health workforce, modernize vaccine systems, prevent the spread of HIV/AIDS, increase public health programs’ effectiveness and efficiency, and improve access to behavioral health services.

Preventing Chronic Disease: A Smart Investment

Chronic diseases – such as heart disease, cancer, stroke, and diabetes – are responsible for 7 out of 10 deaths among Americans each year. They account for 75% of the nation’s health spending. Focusing on prevention can both improve the health of Americans and help control health care spending. In fact, a report from Trust for America’s Health entitled Prevention for a Healthier America concluded that investing $1 in proven community-based programs could yield a return of $5.60. ( ROI almost 6:1)

The Affordable Care Act Section 4106 ( Preventive Services)

Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop S2-26-12
Baltimore, Maryland 21244-1850

Center for Medicaid and CHIP Services
SMD# 13-002
ACA #25

RE: Affordable Care Act Section 4106
(Preventive Services)
February 1, 2013
Dear State Medicaid Director:

This letter provides guidance to states on section 4106 of the Affordable Care Act. Section
4106(b) establishes a one percentage point increase in the federal medical assistance percentage (FMAP) effective January 1, 2013, applied to expenditures for adult vaccines and clinical preventive services to states that cover, without cost-sharing, a full list of specified preventive services and adult vaccines. In that circumstance, the increase would apply to such expenditures whether the services are provided on a fee-for-service (FFS) or managed care basis, or under a benchmark or benchmark-equivalent benefit package (referred to as an alternative benefit plan).

The specified preventive services are those assigned a grade of A or B by the United States
Preventive Services Task Force (USPSTF), and approved vaccines and their administration,
recommended by the Advisory Committee on Immunization Practices (ACIP). The services
remain optional with one exception: effective January 1, 2014, the law requires that alternative benefit plans cover preventive services described in section 2713 of the Public Health Service Act as part of essential health benefits. Section 2713 includes, among others, the same services as those authorized for increased match under section 4106 of the Affordable Care Act.

The federal Agency for Healthcare Research and Quality supports the USPSTF, an independent panel of experts in prevention that makes recommendations on clinical preventive services on a graded scale. The Centers for Disease Control and Prevention supports the ACIP, a group of medical and public health experts that develops recommendations on how to use vaccines to control diseases in the United States. Both groups publish their recommendations. A list of the services that are eligible for the increased FMAP can be found on the following websites:

In order for states to claim the one percentage point FMAP increase for these services, states
must cover in their standard Medicaid benefit package all the recommended preventive services and adult vaccines, and their administration, and must not impose cost-sharing on such services. States’ utilization review and approval procedures should conform to USPSTF and ACIP Page 2 – State Medicaid Director periodicity or indications where specified. States should ensure that they have appropriate codes or modifiers available for providers to utilize a crosswalk from those codes and modifiers to the USPSTF and ACIP recommendations, and a financial monitoring procedure to ensure proper claiming for federal match.

The one percentage point increase to the FMAP under section 4106 applies only to certain
federal matching rates specified in section 1905(b) and section 1905(y) of the Social Security
Act (the Act). Specifically, for eligible services, section 4106 of the Act only applies to the
following FMAP rates, as long as the FMAP does not exceed 100 percent:

• Regular FMAP rates calculated in the first sentence of section 1905(b) of the Act.
• FMAP rates specified in the first sentence of section 1905(b) of the Act for the District of
Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and
American Samoa.
• The enhanced FMAP specified in section 1905(b) of the Act relating to services provided
to certain breast or cervical cancer patients.
• The increased FMAP rates for Medical Assistance for newly eligible mandatory
individuals specified at section 1905(y) of the Act. We note, that although the FMAP
indicated in section 1905(y)(1)(A) of the Act for calendar quarters in 2014, 2015, and
2016 is 100 percent, as indicated above, this FMAP may not exceed 100 percent.

We are adding new lines to the CMS-64 report to capture state expenditures incurred in the
provision of services authorized under section 4106. States should use these new line items to reflect expenditures eligible for the additional one percentage point. As with all services
reimbursed under Medicaid, states are required to maintain documentation supporting
expenditures claimed under these new line items. This documentation must contain the coding, crosswalk, and controls procedures discussed above and must be made available to the Centers for Medicare & Medicaid Services (CMS) upon request.

Overlap with Other Services
We recognize that provision of the preventive services described in section 4106 may occur at the same time as other services eligible for enhanced or increased FMAP rates not identified above. For example, family planning services may include USPSTF preventive services and ACIP approved adult vaccines, and their administration, furnished during a family planning visit.

Family planning services can be reimbursed at a 90 percent rate. In these cases, states should claim on the family planning line of the CMS-64 form, which is reimbursed at the 90 percent rate. If a state ordinarily claims these preventive services and adult vaccines as a separate service from the family planning service, it should continue to do so.

Certain USPSTF grade A or B preventive services and vaccine administration codes eligible for the one percentage point FMAP increase under section 4106 may also qualify as primary care services eligible for a temporary increase in the payment rates matched at 100 percent federal financial participation (FFP) for calendar years (CY) 2013 and 2014 per section 1202 of the Affordable Care Act. Under section 1202, the Medicaid rate in CYs 2013 and 2014 for such primary care services by or under the direction of an eligible physician will be the lower of the provider’s charges or the 2013 and 2014 Medicare rate respectively. FFP is available for 100 Page 3 – State Medicaid Director percent of the difference between the Medicaid rate as of July 1, 2009 and the increased rate.
Under section 1202, the state’s regular FMAP rate will be available for the portion of the rate
related to the July 1, 2009 base payment. An additional one percentage point will be available on that base amount under section 4106 of the Affordable Care Act. The following example illustrates the interaction of these two Affordable Care Act provisions.

Example. A state’s regular FMAP is 60 percent and under section 4106 of the
Affordable Care Act, the FMAP would be increased to 61 percent for certain affected
preventive services effective January 1, 2013. The portion of the state’s rate related to
the July 1, 2009 base payment for certain affected primary care preventive services is
$70. In 2013 the state increases the rate to $80 in accordance with section 1202 of the
Affordable Care Act. The $10 difference between the $70 July 1, 2009 Medicaid rate
and the increased rate of $80 is eligible under section 1202 of the Affordable Care Act for
100 percent FMAP. Prior to the application of the Affordable Care Act provisions, the
total federal funding for the $70 provider payment rate would have been $42 (60 percent
FMAP of $70). With the application of section 4106 and 1202 of the Affordable Care
Act, the total federal funding available would be $52.70, calculated as $42.70 (61% (60
percent FMAP plus one percentage point) of the $70 regular provider rate) plus $10 (100
percent of the difference between $80 (the increased provider rate) and $70 (the July 1,
2009 rate)).

Claiming the Increased FMAP in Managed Care

In order to be eligible for the one percentage point increased FMAP, states must make these
services available to those enrolled in a managed care delivery system as well as those in a FFS setting, and must ensure that beneficiaries have no cost-sharing liability for these services. States have the authority to claim an increased FMAP for preventive services whether provided in a FFS setting or in a managed care program that is reimbursed through capitation rates that meet the requirements for actuarial soundness in 42 CFR 438.6(c).

The portion of the capitated rate that is attributable to preventive services and upon which an increased match may be claimed, may be determined prospectively based upon historical FFS data or data from the managed care plans (if available). The portion of the capitation rate claimed at the increased FMAP must be attributable only to services meeting the definition for preventive services under this section. The data used to establish the portion of the capitation rate that can be claimed at the increased FMAP rate should be the most recent complete and validated historical data available, whether from FFS or the managed care plans. In order to claim the increased FMAP states may need to amend their managed care contracts to require delivery of these services in accordance with the statute.

State Plan Modifications

States seeking the one percentage point FMAP increase should amend their state plans to reflect that they cover and reimburse all USPSTF grade A and B preventive services and approved vaccines recommended by ACIP, and their administration, without cost-sharing. States should provide an assurance in the state plan indicating that they have documentation available to support the claiming of federal match for such services, as described earlier in this letter. States Page 4 – State Medicaid Director should provide an additional assurance stating that they have a method to ensure that, as changes
are made to USPSTF or ACIP recommendations, they will update their coverage and billing
codes to comply with those revisions. Please refer to the previously mentioned websites for
USPSTF and ACIP updates.

Additional Policy Development

Certain preventive services listed by the USPSTF when provided by non-licensed practitioners have traditionally not been covered by Medicaid due to regulatory requirements limiting practitioners of preventive services to either physicians or licensed professionals. Although section 1905(a)(13) of the Act contains broad language authorizing payment for preventive services recommended by a physician or other licensed practitioner, the implementing regulation at 42 CFR 440.130(c) currently limits preventive services to those provided by a physician or other licensed practitioner of the healing arts (within the scope of practice under state law).

Consistent with 4106(a), CMS proposed revisions to this regulation in the Notice of Proposed
Rule making which went on display in the Federal Register on January 14, 2013, giving states the ability to recognize unlicensed practitioners in the delivery of these services. Should this policy be finalized, states would be able to claim the one percentage point match for preventive services delivered by practitioners other than physicians or other licensed practitioners. Until that time, however, the increased match is available only for those services that are delivered in accordance with existing Medicaid regulations.

We are eager to work with states to facilitate the implementation of these preventive services that can improve the health of beneficiaries. As you continue to consider and implement measures aimed at strengthening prevention, we are available to provide technical assistance on prevention related topics if you email us at:

 If you have any questions regarding this letter, please contact Barbara Edwards, Director of the Disabled and Elderly Health Programs Group, at 410-786-0325.

Cindy Mann