| PRA Disclosure Statement This information collection request is required by states to obtain benefits. It provides for the collection of access-related data as required by section 1902(a)(30)(A) of the Social Security Act (the Act). 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 0938-1134. The time required to complete this information collection is estimated to average between 48 hours and 264 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. |
| Purpose of Rate Reduction or Restructuring Template | |
As described at 42 CFR 447.203 and 447.204, implementing section 1902(a)(30)(A) of the Social Security Act (the Act), states, the District of Columbia, and U.S. territories (hereafter referred to as states) are required to document that Medicaid payment rates are sufficient to enlist enough providers so that care and services are available under the state plan at least to the extent that such care and services are available to the general population in the geographic area. This template allows a state to demonstrate compliance with criteria described in 42 CFR 447.203(c)(1) and provide CMS with information required in 42 CFR 447.203(c)(2) when a state's proposed rate reductions or restructurings do not meet the requirements in 42 CFR 447.203(c)(1). The information in this template will be reviewed as part of the state plan amendment (SPA) review process. |
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| Submission and Communications | |
- Completed forms should be submitted to the OneMAC Submission Portal or SPA@cms.hhs.gov with the submission of a proposed rate reductions or restructuring SPA. - Questions about this form may be directed to MedicaidAccesstoCare@cms.hhs.gov. |
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| Rate Reduction or Restructuring Template Organization | |
| Consistent with 42 CFR 447.203 and 447.204, this template provides space for a state to demonstrate compliance with fee-for-service access to care requirements. As described in 42 CFR 447.203(c)(1), for any SPA that proposes to reduce provider payment rates or restructure provider payments in circumstances when the changes could result in diminished access, the following three criteria must be met: 1: Medicaid payment rates in the aggregate (including base and supplemental payments) following the proposed reduction or restructuring for each benefit category affected by the proposed reduction or restructuring will be at or above 80 percent of the most recently published Medicare payment rates for the same or a comparable set of Medicare-covered services. If there is no same or comparable set of Medicare-covered services, this criterion cannot be met and the state must complete the additional reporting in the remaining tabs (color-coded in blue) of this workbook as described in 42 CFR 447.203(c)(2). 2: Proposed reduction or restructuring, including the cumulative effect of all reductions or restructurings taken throughout the current state fiscal year, will be likely to result in no more than a 4 percent reduction in aggregate fee-for-service Medicaid expenditures for each benefit category affected by proposed reduction or restructuring within a state fiscal year. 3: Public processes yielded no significant access to care concerns from beneficiaries, providers, or other interested parties regarding the service(s) for which the payment rate reduction or payment restructuring is proposed, or if such processes did yield concerns, the state can reasonably respond to or mitigate the concerns, as appropriate. A state will use the following tabs (color-coded in green) within this template to demonstrate compliance with the three criteria above: (1) "0 Summary of compliance" tab (2) "I 80% Medicare" tab (3) "II 4% Aggregate" tab (4) "III Public Process Attestation" tab If the three criteria are not met, the state must complete additional analyses in the remaining tabs (color-coded in blue) of this workbook as described in 42 CFR 447.203(c)(2). Within this template, a state shall report all data in the BEIGE COLORED CELLS. Tabs are organized as follows: |
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| Tab name: | Tab topic: |
| State Attestation | Attestation that the template is true, accurate, and complete, and has been prepared in accordance with applicable instructions |
| 0 Summary of compliance | Summary of state contact information and state compliance with the three criteria, as shown in tabs I through III, required for any rate reduction or restructuring |
| I 80% Medicare | Comparison of aggregate Medicaid rates following the proposed SPA to Medicare rates to ensure Medicaid rates under the proposed rate reduction or restructuring are at or above 80% of the most recently published Medicare rates |
| II 4% Aggregate | Comparison of estimated aggregate expenditures after proposed rate reduction or restructuring and prior years' expenditures |
| III Public Process Attestation | Attestation of compliance with public process |
| IV Addl - Analysis | Additional rate analysis; to be completed if the three criteria, as shown in tabs I through III, are not met |
| V Addl - Providers | Additional provider analysis; to be completed if the three criteria, as shown in tabs I through III, are not met |
| VI Addl - Beneficiary | Additional beneficiary access analysis; to be completed if the three criteria, as shown in tabs I through III, are not met |
| VII Addl - Services | Additional service utilization analysis; to be completed if the three criteria, as shown in tabs I through III, are not met |
| VIII Addl - Concerns | Additional summary of concerns from the public process and state responses; to be completed if the three criteria, as shown in tabs I through III, are not met |
| OMB Approved # 0938-1134 Expires TBD |
| Rate Reduction or Restructuring Template Instructions | ||||
| The state is required to enter data on the following tabs: (1) "I 80% Medicare" (2) "II 4% Aggregate", and (3) "III Public Process Attestation." State-submitted information in these tabs will be used to demonstrate compliance with the three criteria required for any proposed rate reduction or restructuring (see "Overview" tab for more details on the three criteria). The state can track progress toward meeting the three criteria on the "0 Summary of compliance" tab. If the three criteria on tabs I through III are not met, the state must complete additional analyses related to the rate reduction or restructuring for each affected benefit category in the following tabs: - "IV Addl - Analysis" - "V Addl - Providers" - "VI Addl - Beneficiary" - "VII Addl - Services" - "VIII Addl - Concerns" Instructions on how to use the tabs in this workbook are provided below. The state must also complete the "State Attestation" tab to confirm the accuracy, completeness, and compliance with the instructions detailed on this tab. |
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| Instructions for Information Required for All State Plan Amendments Proposing Rate Reduction or Restructuring | ||||
0. "Summary of compliance" tab |
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| 0.A. Primary contact information | ||||
| 0.A.1-0.A.4: The state must enter the Name, Phone Number, Email Address, and Title of the Primary Contact related to this template. Follow-up communications related to this template will be made with the primary contact. | ||||
| 0.A.5: The state must select the relevant state name from the drop down for the name of the state/territory agency that is submitting this report. | ||||
| 0.A.6: The state must enter the state agency that is submitting this report. | ||||
0.B. Rate reduction or restructuring criteria |
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| The state will not enter any data in this section. This section allows a state to track whether each of the three criterion in 42 CFR 447.203(c)(1) has been met based on the information provided on the "I 80% Medicare" tab, the "II 4% Aggregate" tab, and the "III Public Process Attestation" tab. Cells where the criterion is "Met" will read "Met" and be shaded in green. Cells where the criterion is "Not Met" will read "Not Met" and be shaded in red. Cells that are incomplete will read "N/A" and be shaded in gray. | ||||
| 0.B.1: This row assesses whether the state has met criterion #1 in 42 CFR 447.203(c)(1)(i) based on data provided in the "I 80% Medicare" tab. If the aggregate Medicaid payment rates are at or above 80 percent of the most recently published Medicare payment rates, as calculated in the "I 80% Medicare" tab, then criterion #1 will be considered "Met." |
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| 0.B.2: This row assesses whether the state has met criterion #2 in 42 CFR 447.203(c)(1)(ii) based on data provided in the "II 4% Aggregate" tab. If the state demonstrates that the proposed reduction or restructuring is likely to result in no more than a 4 percent reduction in aggregate fee-for-service Medicaid expenditures for each row in the "II 4% Aggregate" tab, then criterion #2 will be considered "Met." | ||||
| 0.B.3: This row assesses whether the state has met criterion #3 in 42 CFR 447.203(c)(1)(iii) based on data provided in the "III Public Process Attestation" tab. If the state has attested that the public processes yielded no significant access to care concerns from beneficiaries, providers, or other interested parties regarding the service(s) for which the payment rate reduction or payment restructuring is proposed, or if such processes did yield concerns, and the state can reasonably respond to or mitigate the concerns, as appropriate, then criterion #3 will be considered "Met." | ||||
| 0.C.1: If the state meets the rate reduction or restructuring criteria as described in 42 CFR 447.203(c)(1)(i) through (iii), the state must describe its procedures for monitoring continued compliance with section 1902(a)(30)(A), as described in 42 CFR 447.203(c)(1). | ||||
I. "80% Medicare" tab |
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| I.A. Initial state analysis for rate reduction or restructuring | ||||
| This section allows the state to demonstrate compliance with criterion #1 in 42 CFR 447.203(c)(1)(i) (aggregate Medicaid payment rates following the proposed reduction or restructuring are at or above 80 percent of the most recently published Medicare payment rates for the same or comparable set of Medicare-covered services). The state will populate one row for each benefit category (e.g., primary care services, obstetrical and gynecological services, behavioral health outpatient services, home and community based services) with a proposed rate reduction or restructuring. The state must populate the requested information in the BEIGE COLORED CELLS in columns B through F. | ||||
| Details regarding the requested information are below: | ||||
| Data element | Column | Data format | Instructions and definition | |
| Name of SPA | B | Free text | Enter the name of the State Plan Amendment (SPA) that contains the rate reduction or restructuring. | |
| Date SPA submitted | C | Free text | Enter the date the SPA was submitted. | |
| Benefit category | D | Free text | Enter the benefit category associated with the rate reduction or restructuring in the SPA (e.g., primary care services, obstetrical and gynecological services, behavioral health outpatient services, home and community based services). | |
| Sum of individual ratios | E | Percentage | Enter the sum of the individual ratios for individual constituent services within the benefit category. To derive a ratio for individual constituent services, perform a comparison of the Medicaid to the Medicare payment rate on a code-by-code basis, meaning CPT, CDT, or HCPCS, as applicable. Express the sum as a percentage. For example, express the sum of 0.75 and 0.90 as 165%. Use cell A5 to indicate the time period of the Medicare payment rates used to compute the individual ratios summed in column E. | |
| Number of individual ratios | F | Number | Enter the number of ratios contributing to the sum in column E. | |
| Rate reduction or restructuring percentage | G | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column calculates the sum of individual ratios compared to the number of individual ratios entered by the state. | |
| Rate reduction or restructuring criterion met | H | Text (auto populated) | The state does not need to enter any data in this row as it is auto populated. This column identifies whether the state has met criterion #1 in 42 CFR 447.203(c)(1)(i) for each row on the tab. | |
II. "4% Aggregate" tab |
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| II.A. Aggregate FFS Medicaid expenditures | ||||
| This section allows the state to demonstrate compliance with criterion #2 in 42 CFR 447.203(c)(1)(ii) (proposed reduction or restructuring would be likely to result in no more than a 4 percent reduction in aggregate fee-for-service Medicaid expenditures for each benefit category). The state must populate the requested information in the BEIGE COLORED CELLS in columns E through F. | ||||
| Details regarding the requested information are below: | ||||
| Data element | Column | Data format | Instructions and definition | |
| Name of SPA | B | Free text (auto populated) | Auto populated with the name of the State Plan Amendment (SPA) as entered on the "I 80% Medicare" tab | |
| Date SPA submitted | C | Free text (auto populated) | Auto populated with the date the SPA was submitted as entered on the "I 80% Medicare" tab | |
| Benefit category | D | Free text (auto populated) | Auto populated with the benefit category as entered on the "I 80% Medicare" tab | |
| Estimated expenditures | E | Dollar amount | Enter estimated expenditures AFTER rate reduction or restructuring. | |
| Prior year expenditures | F | Dollar amount | Enter prior year expenditures submitted on the state's Form CMS-64. Use cell A5 to indicate the time period of the expenditures in Column F. | |
| Comparison of expenditures | G | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column calculates the estimated expenditures / prior year expenditures minus one. | |
| Rate reduction or restructuring criterion met | H | Text (auto populated) | The state does not need to enter any data in this row as it is auto populated. This column identifies whether the state has met criterion #2 for each row on the tab. | |
III. "Public Process Attestation" tab |
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| This section allows the state to demonstrate compliance with criterion #3 in 42 CFR 447.203(c)(1)(iii) (Public processes yielded no significant access to care concerns from beneficiaries, providers, or other interested parties regarding the service(s) for which the payment rate reduction or payment restructuring is proposed, or if such processes did yield concerns, the state can reasonably respond to or mitigate the concerns, as appropriate, as documented in the analysis provided by the state). The state must read and attest to the statement on the tab. For reference, information on significant concerns can be found in the Ensuring Access to Medicaid Services Final Rule (CMS-2442-F, p 40782). |
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| Additional Analyses (to be completed if the SPA does not meet the three criteria, as shown in tabs I through III) | ||||
| For any SPA that does not meet the three criteria required for all SPAs proposing rate reduction or restructuring that could result in diminished access, as shown in tabs I through III, the state must demonstrate that the proposed payment rates and structure would be sufficient to enlist enough providers so that covered services would be available to beneficiaries at least to the same extent as to the general population in the geographic area. To do so, the state must fill out the following five tabs for each benefit category affected by the proposed rate reduction or restructuring. | ||||
IV. "Addl - Analysis" tab |
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IV.A. Summary of the proposed payment change |
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| IV.A.1: The state will provide a summary of the proposed payment change. The summary must include the reason for the proposal and a description of any policy purpose for the proposed change, including the cumulative effect of all reductions or restructurings taken throughout the current state fiscal year in aggregate fee-for-service Medicaid expenditures for each benefit category affected by proposed reduction or restructuring within a state fiscal year. | ||||
IV.B. Aggregate rate changes |
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| This section allows the state to provide information on Medicaid payment rates in the aggregate (including base and supplemental payments) before and after the proposed reduction or restructuring for each affected benefit category and a comparison of each to the most recently published Medicare payment rates for the same or a comparable set of Medicare-covered services and, as reasonably feasible, to the most recently available payment rates of other health care payers in the state or the geographic area for the same or a comparable set of covered services. The state must populate the requested information in the BEIGE COLORED CELLS in columns B through I. | ||||
| Details regarding the requested information are below: | ||||
| Data element | Column | Data format | Instructions and definition | |
| Benefit category | B | Free text | Enter the benefit category associated with the rate reduction or restructuring in the SPA (i.e., all individual services under a category of services described in section 1905(a) of the Act for which the State is proposing a payment rate reduction or restructuring). | |
| Sum of the Medicaid payment rates in the aggregate BEFORE rate reduction or restructuring | C | Dollar | Enter the dollar ($) value of the sum of the Medicaid fee-for-service payment rates in the benefit category, including any base and supplemental payments for services before rate reduction or restructuring. | |
| Sum of the Medicaid payment rates in the aggregate AFTER rate reduction or restructuring | D | Dollar | Enter the dollar ($) value of the sum of the Medicaid fee-for-service payment rates in the benefit category, including any base and supplemental payments for services after rate reduction or restructuring. | |
| Number of Individual Ratios | E | Number | Enter the number of rates contributing to the sum in columns C or D. | |
| Sum of the ratios of Medicaid payment rates to the comparable Medicare rate BEFORE rate reduction or restructuring | F | Percentage | Create a ratio of each Medicaid payment rate BEFORE reduction/restructuring to its comparable Medicare rate and sum the ratios together. Report this sum as a percentage. Use cell A9 to indicate the time period of the Medicare payment rates used to compute the individual ratios. | |
| Sum of the ratios of Medicaid payment rates to the comparable other health care payer rate BEFORE rate reduction or restructuring | G | Percentage | Create a ratio of each Medicaid payment rate BEFORE reduction/restructuring to its comparable health care payer rate and sum the ratios together. Report this sum as a percentage. Use cell B9 to indicate the time period of the other health care payer rates used to compute the individual ratios. | |
| Sum of the ratios of Medicaid payment rates to the comparable Medicare rate AFTER rate reduction or restructuring | H | Percentage | Create a ratio of each Medicaid payment rate AFTER reduction/restructuring to its comparable Medicare rate and sum the ratios together. Report this sum as a percentage. | |
| Sum of the ratios of Medicaid payment rates to the comparable other health care payer rate AFTER rate reduction or restructuring | I | Percentage | Create a ratio of each Medicaid payment rate AFTER reduction/restructuring to its comparable health care payer rate and sum the ratios together. Report this sum as a percentage. | |
| Average taken of the ratios of Medicaid rates (BEFORE rate reduction or restructuring) to Medicare | J | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column calculates the Medicaid payment amount before rate reduction or restructuring / Medicare payment amount. | |
| Average taken of the ratios of Medicaid rates (BEFORE rate reduction or restructuring) to health care payer | K | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column calculates the Medicaid payment amount before rate reduction or restructuring / health care payer payment amount. | |
| Average taken of the ratios of Medicaid rates (AFTER rate reduction or restructuring) to Medicare | L | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column calculates the Medicaid payment amount after rate reduction or restructuring / Medicare payment amount. | |
| Average taken of the ratios of Medicaid rates (AFTER rate reduction or restructuring) to health care payer |
M | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column calculates the Medicaid payment amount after rate reduction or restructuring / health care payer payment amount | |
V. "Addl - Providers" tab |
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| V.A. Three years preceding the SPA submission date | ||||
| V.A.1-A.3: The state must define the three years preceding the proposed SPA by entering the start and end dates in the BEIGE COLORED CELLS in columns D and E. The state will use the most recent and complete data available. | ||||
| V.B. Actively participating providers of services | ||||
| This section allows the state to provide additional details on the number of actively participating providers of services for each benefit category affected by the proposed reduction or restructuring for each of the 3 years immediately preceding the SPA submission date, by state-specified geographic area, provider type, and site of service. Note that for this purpose, an actively participating provider is a provider that is participating in the Medicaid program and actively seeing and providing services to Medicaid beneficiaries, or accepting Medicaid beneficiaries as new patients. The state must populate the requested information in the BEIGE COLORED CELLS in columns C through H and in columns M through N. | ||||
| Details regarding the requested information are below: | ||||
| Data element | Column | Data format | Instructions and definition | |
| Benefit category | B | Free text (auto populated) | Auto populated with the benefit category as entered on the "IV Addl - Analysis" tab | |
| State-specified geographic region | C | Free text | Enter the state-specified geographic region (for example, county or parish) | |
| Provider type | D | Free text | Enter the provider type(s) affected by the reduction or restructuring, such as, but not limited to, physician, pharmacist, hospital, home health agency, assisted living facility, etc. | |
| Site of service | E | Free text | Enter the site(s) of service affected by the reduction or restructuring, such as, but not limited to, home, hospital, assisted living facility, school, office etc. | |
| Number of actively participating providers - Year 1 | F | Number | Enter the number of actively participating providers for the affected benefit category for Year 1, where Year 1 is the time period defined in item V.A.1 | |
| Number of actively participating providers - Year 2 | G | Number | Enter the number of actively participating providers for the affected benefit category for Year 2, where Year 2 is the time period defined in item V.A.2 | |
| Number of actively participating providers - Year 3 | H | Number | Enter the number of actively participating providers for the affected benefit category for Year 3, where Year 3 is the time period defined in item V.A.3 | |
| Trend from Year 1 to Year 2 | I | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of actively participating providers - Year 2 with the number of actively participating providers - Year 1. | |
| Trend from Year 2 to Year 3 | J | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of actively participating providers - Year 3 with the number of actively participating providers - Year 2. | |
| Change from Year 1 to Year 3 | K | Number (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column calculates the number of actively participating providers - Year 3 minus the number of actively participating providers - Year 1. | |
| Trend from Year 1 to Year 3 | L | Text and percentage change (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column describes the trend of the number of actively participating providers from Year 1 to Year 3. | |
| Description of trends | M | Free text | Enter a description of observed trends for each geographic area over the 3 year period. | |
| Anticipated effect of rate reduction or restructuring | N | Free text | Provide an estimate of the anticipated effect of the rate reduction or restructuring on the number of actively participating providers in each benefit category, by geographic area. | |
VI. "Addl - Beneficiary" tab |
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| VI.A. Three years preceding the SPA submission date | ||||
| VI.A.1-A.3: The state must define the three years preceding the proposed SPA by entering the start and end dates in the BEIGE COLORED CELLS in columns D and E. The state will use the most recent and complete data available. | ||||
| VI.B. Beneficiaries receiving services through fee-for-service (FFS) delivery system | ||||
| This section allows the state to provide qualitative information about the beneficiaries that receive services furnished through a FFS delivery system for each benefit category affected by the proposed rate reduction or restructuring over the three year period. The state must populate the requested information in the BEIGE COLORED CELLS in column D. | ||||
| VI.B.1: The state must describe the demographic characteristics of the beneficiary populations receiving services affected by the rate reduction or restructuring. | ||||
| VI.B.2: The state must describe how the proposed rate reduction or restructuring may affect access to care and service delivery for beneficiaries in various populations. | ||||
| VI.B.3: If additional space is needed, the state may provide qualitative information in a separate document and must provide the file name of the document containing additional information and any applicable page numbers. | ||||
| VI.C. Beneficiaries receiving services through FFS delivery system | ||||
| This section allows the state to provide quantitative information on the beneficiaries receiving services affected by the rate reduction or restructuring for the three years, by geographic area. The state will include beneficiaries who received services through the FFS delivery system in each benefit category affected by the proposed payment rate reduction or payment restructuring. The state must populate the requested information in the BEIGE COLORED CELLS in columns C through O and columns AO through AP. | ||||
| Details regarding the requested information are below: | ||||
| Data element | Column | Data format | Instructions and definition | |
| Benefit category | B | Free text (auto populated) | Auto populated with the benefit category as entered on the "IV Addl - Analysis" tab | |
| State-specified geographic region | C | Free text | Enter the state-specified geographic region (for example, county or parish). | |
| Total number of beneficiaries receiving services - Year 1 | D | Number | Enter the total number of beneficiaries receiving services for Year 1, where Year 1 is the time period defined in VI.A.1. | |
| Total number of beneficiaries receiving services - Year 2 | E | Number | Enter the total number of beneficiaries receiving services for Year 2, where Year 2 is the time period defined in VI.A.2. | |
| Total number of beneficiaries receiving services - Year 3 | F | Number | Enter the total number of beneficiaries receiving services for Year 3, where Year 3 is the time period defined in VI.A.3. | |
| Number of adult beneficiaries receiving services - Year 1 | G | Number | Enter the number of adult beneficiaries receiving services for Year 1, where Year 1 is the time period defined in VI.A.1. | |
| Number of adult beneficiaries receiving services - Year 2 | H | Number | Enter the number of adult beneficiaries receiving services for Year 2, where Year 2 is the time period defined in VI.A.2. | |
| Number of adult beneficiaries receiving services - Year 3 | I | Number | Enter the number of adult beneficiaries receiving services for Year 3, where Year 3 is the time period defined in VI.A.3. | |
| Number of child beneficiaries receiving services - Year 1 | J | Number | Enter the number of child beneficiaries receiving services for Year 1, where Year 1 is the time period defined in VI.A.1. | |
| Number of child beneficiaries receiving services - Year 2 | K | Number | Enter the number of child beneficiaries receiving services for Year 2, where Year 2 is the time period defined in VI.A.2. | |
| Number of child beneficiaries receiving services - Year 3 | L | Number | Enter the number of child beneficiaries receiving services for Year 3, where Year 3 is the time period defined in VI.A.3. | |
| Number of beneficiaries who are living with disabilities receiving services - Year 1 | M | Number | Enter the number of beneficiaries who are living with disabilities receiving services for Year 1, where Year 1 is the time period defined in VI.A.1. Note that this number is not mutually exclusive of the adults and child numbers above. | |
| Number of beneficiaries who are living with disabilities receiving services - Year 2 | N | Number | Enter the number of beneficiaries who are living with disabilities receiving services for Year 2, where Year 2 is the time period defined in VI.A.2. Note that this number is not mutually exclusive of the adults and child numbers above. | |
| Number of beneficiaries who are living with disabilities receiving services - Year 3 | O | Number | Enter the number of beneficiaries who are living with disabilities receiving services for Year 3, where Year 3 is the time period defined in VI.A.3. Note that this number is not mutually exclusive of the adults and child numbers above. | |
| Proportion of beneficiaries who are adults - Year 1 | P | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of adult beneficiaries receiving services - Year 1 with the total number of beneficiaries receiving services - Year 1. | |
| Proportion of beneficiaries who are adults - Year 2 | Q | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of adult beneficiaries receiving services - Year 2 with the total number of beneficiaries receiving services - Year 2. | |
| Proportion of beneficiaries who are adults - Year 3 | R | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of adult beneficiaries receiving services - Year 3 with the total number of beneficiaries receiving services - Year 3. | |
| Proportion of beneficiaries who are children - Year 1 | S | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of child beneficiaries receiving services - Year 1 with the total number of beneficiaries receiving services - Year 1. | |
| Proportion of beneficiaries who are children - Year 2 | T | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of child beneficiaries receiving services - Year 2 with the total number of beneficiaries receiving services - Year 2. | |
| Proportion of beneficiaries who are children - Year 3 | U | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of child beneficiaries receiving services - Year 3 with the total number of beneficiaries receiving services - Year 3. | |
| Proportion of beneficiaries who are living with disabilities - Year 1 | V | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of beneficiaries who are living with disabilities receiving services - Year 1 with the total number of beneficiaries receiving services - Year 1. | |
| Proportion of beneficiaries who are living with disabilities - Year 2 | W | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of beneficiaries who are living with disabilities receiving services - Year 2 with the total number of beneficiaries receiving services - Year 2. | |
| Proportion of beneficiaries who are living with disabilities - Year 3 | X | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of beneficiaries who are living with disabilities receiving services - Year 3 with the total number of beneficiaries receiving services - Year 3. | |
| Trend of total number of beneficiaries receiving services from Year 1 to Year 2 | Y | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the total number of beneficiaries receiving services - Year 2 with the total number of beneficiaries receiving services - Year 1. | |
| Trend of total number of beneficiaries receiving services from Year 2 to Year 3 | Z | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the total number of beneficiaries receiving services - Year 3 with the total number of beneficiaries receiving services - Year 2. | |
| Change in total number of beneficiaries receiving services from Year 1 to Year 3 | AA | Number (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column calculates the total number of beneficiaries receiving services - Year 3 minus the total number of beneficiaries receiving services - Year 1. | |
| Trend of total number of beneficiaries receiving services from Year 1 to Year 3 | AB | Text and percentage change (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column describes the trend of total number of beneficiaries receiving services from Year 1 to Year 3. | |
| Trend of number of adult beneficiaries receiving services from Year 1 to Year 2 | AC | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of adult beneficiaries receiving services - Year 2 with the number of adult beneficiaries receiving services - Year 1. | |
| Trend of number of adult beneficiaries receiving services from Year 2 to Year 3 | AD | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of adult beneficiaries receiving services - Year 3 with the number of adult beneficiaries receiving services - Year 2. | |
| Change in number of adult beneficiaries receiving services from Year 1 to Year 3 | AE | Number (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column calculates the number of adult beneficiaries receiving services - Year 3 minus the number of adult beneficiaries receiving services - Year 1. | |
| Trend of number of adult beneficiaries receiving services from Year 1 to Year 3 | AF | Text and percentage change (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column describes the trend of the number of adult beneficiaries receiving services from Year 1 to Year 3. | |
| Trend of number of child beneficiaries receiving services from Year 1 to Year 2 | AG | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of child beneficiaries receiving services - Year 2 with the number of child beneficiaries receiving services - Year 1. | |
| Trend of number of child beneficiaries receiving services from Year 2 to Year 3 | AH | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of child beneficiaries receiving services - Year 3 with the number of child beneficiaries receiving services - Year 2. | |
| Change in number of child beneficiaries receiving services from Year 1 to Year 3 | AI | Number (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column calculates the number of child beneficiaries receiving services - Year 3 minus the number of child beneficiaries receiving services - Year 1. | |
| Trend of number of child beneficiaries receiving services from Year 1 to Year 3 | AJ | Text and percentage change (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column describes the trend of the number of child beneficiaries receiving services from Year 1 to Year 3. | |
| Trend of number of beneficiaries who are living with disabilities receiving services from Year 1 to Year 2 | AK | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of beneficiaries who are living with disabilities receiving services - Year 2 with the number of beneficiaries who are living with disabilities receiving services - Year 1. | |
| Trend of number of beneficiaries who are living with disabilities receiving services from Year 2 to Year 3 | AL | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of beneficiaries who are living with disabilities receiving services - Year 3 with the number of beneficiaries who are living with disabilities receiving services - Year 2. | |
| Change in number of beneficiaries who are living with disabilities receiving services from Year 1 to Year 3 | AM | Number (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column calculates the number of beneficiaries who are living with disabilities receiving services - Year 3 minus the number of beneficiaries who are living with disabilities receiving services - Year 1. | |
| Trend of number of beneficiaries who are living with disabilities receiving services from Year 1 to Year 3 | AN | Text and percentage change (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column describes the trend of the number of beneficiaries who are living with disabilities receiving services from Year 1 to Year 3. | |
| Description of trends | AO | Free text | Enter a description of observed trends for each geographic area over the 3 year period. | |
| Anticipated effect of rate reduction or restructuring | AP | Free text | Provide an estimate of the anticipated effect of the rate reduction or restructuring on the number beneficiaries receiving services in each benefit category, by geographic area | |
VII. "Addl Services" tabs |
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| VII.A. Three years preceding the SPA submission date | ||||
| VII.A.1-A.3: The state must define the three years preceding the proposed SPA by entering the start and end dates in the BEIGE COLORED CELLS in columns D and E. The state will use the most recent and complete data available. | ||||
| VII.B. Medicaid services furnished through FFS delivery system | ||||
| This section allows the state to provide qualitative information on services furnished through the FFS delivery system in each benefit category affected by the proposed reduction or restructuring over the three year period. The state must populate the requested information in the BEIGE COLORED CELLS in column D. | ||||
| VII.B.1: The state must describe services affected by the rate reduction or restructuring. | ||||
| VII.B.2: The state must describe how the proposed rate reduction or restructuring may affect access to care and service delivery. | ||||
| VII.B.3: If additional space is needed, the state may provide qualitative information in a separate document and must provide the file name of the document containing additional information and any applicable page numbers. | ||||
| VII.C. Medicaid services furnished through FFS delivery system | ||||
| This section allows the state to provide quantitative information on services furnished through the FFS delivery system in each benefit category affected by the proposed reduction or restructuring over the three year period, by geographic area, provider type, and site of service. The state must populate the requested information in the BEIGE COLORED CELLS in columns F through Q and columns AQ through AR. | ||||
| Details regarding the requested information are below: | ||||
| Data element | Column | Data format | Instructions and definition | |
| Benefit category | B | Free text (auto populated) | Auto populated with the benefit category as entered on the "IV Addl - Analysis" tab | |
| State-specified geographic region | C | Auto populated | Auto populated from the state-specified geographic region used on the "Addl - Providers" tab | |
| Provider type | D | Auto populated | Auto populated from the provider type used on the "Addl - Providers" tab | |
| Site of service | E | Auto populated | Auto populated from the site of service used on the "Addl - Providers" tab | |
| Number of Medicaid services furnished through FFS - Year 1 | F | Number | Enter the total number Medicaid services furnished through FFS for Year 1, where Year 1 is the time period defined in VII.A.1. | |
| Number of Medicaid services furnished through FFS - Year 2 | G | Number | Enter the total number Medicaid services furnished through FFS for Year 2, where Year 2 is the time period defined in VII.A.2. | |
| Number of Medicaid services furnished through FFS - Year 3 | H | Number | Enter the total number Medicaid services furnished through FFS for Year 3, where Year 3 is the time period defined in VII.A.3. | |
| Number of Medicaid services furnished to adult beneficiaries - Year 1 | I | Number | Enter the number of Medicaid services furnished to adult beneficiaries for Year 1, where Year 1 is the time period defined in VII.A.1. | |
| Number of Medicaid services furnished to adult beneficiaries - Year 2 | J | Number | Enter the number of Medicaid services furnished to adult beneficiaries for Year 2, where Year 2 is the time period defined in VII.A.2. | |
| Number of Medicaid services furnished to adult beneficiaries - Year 3 | K | Number | Enter the number of Medicaid services furnished to adult beneficiaries for Year 3, where Year 3 is the time period defined in VII.A.3. | |
| Number of Medicaid services furnished to child beneficiaries - Year 1 | L | Number | Enter the number of Medicaid services furnished to child beneficiaries for Year 1, where Year 1 is the time period defined in VII.A.1. | |
| Number of Medicaid services furnished to child beneficiaries - Year 2 | M | Number | Enter the number of Medicaid services furnished to child beneficiaries for Year 2, where Year 2 is the time period defined in VII.A.2. | |
| Number of Medicaid services furnished to child beneficiaries - Year 3 | N | Number | Enter the number of Medicaid services furnished to child beneficiaries for Year 3, where Year 3 is the time period defined in VII.A.3. | |
| Number of Medicaid services furnished to beneficiaries who are living with disabilities - Year 1 | O | Number | Enter the number of Medicaid services furnished to beneficiaries who are living with disabilities for Year 1, where Year 1 is the time period defined in VII.A.1. | |
| Number of Medicaid services furnished to beneficiaries who are living with disabilities - Year 2 | P | Number | Enter the number of Medicaid services furnished to beneficiaries who are living with disabilities for Year 2, where Year 2 is the time period defined in VII.A.2. | |
| Number of Medicaid services furnished to beneficiaries who are living with disabilities - Year 3 | Q | Number | Enter the number of Medicaid services furnished to beneficiaries who are living with disabilities for Year 3, where Year 3 is the time period defined in VII.A.3. | |
| Proportion of Medicaid services furnished to adult beneficiaries - Year 1 | R | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of Medicaid services furnished to adult beneficiaries - Year 1 with the number of Medicaid services furnished through FFS - Year 1. | |
| Proportion of Medicaid services furnished to adult beneficiaries - Year 2 | S | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of Medicaid services furnished to adult beneficiaries - Year 2 with the number of Medicaid services furnished through FFS - Year 2. | |
| Proportion of Medicaid services furnished to adult beneficiaries - Year 3 | T | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of Medicaid services furnished to adult beneficiaries - Year 3 with the number of Medicaid services furnished through FFS - Year 3. | |
| Proportion of Medicaid services furnished to child beneficiaries - Year 1 | U | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of Medicaid services furnished to child beneficiaries - Year 1 with the number of Medicaid services furnished through FFS - Year 1. | |
| Proportion of Medicaid services furnished to child beneficiaries - Year 2 | V | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of Medicaid services furnished to child beneficiaries - Year 2 with the number of Medicaid services furnished through FFS - Year 2. | |
| Proportion of Medicaid services furnished to child beneficiaries - Year 3 | W | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of Medicaid services furnished to child beneficiaries - Year 3 with the number of Medicaid services furnished through FFS - Year 3. | |
| Proportion of Medicaid services furnished to beneficiaries living with disabilities - Year 1 | X | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of Medicaid services furnished to beneficiaries who are living with disabilities - Year 1 with the number of Medicaid services furnished through FFS - Year 1. | |
| Proportion of Medicaid services furnished to beneficiaries living with disabilities - Year 2 | Y | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of Medicaid services furnished to beneficiaries who are living with disabilities - Year 2 with the number of Medicaid services furnished through FFS - Year 2. | |
| Proportion of Medicaid services furnished to beneficiaries living with disabilities - Year 3 | Z | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares the number of Medicaid services furnished to beneficiaries who are living with disabilities - Year 3 with the number of Medicaid services furnished through FFS - Year 3. | |
| Trend of Medicaid services furnished through FFS from Year 1 to Year 2 | AA | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares Medicaid services furnished through FFS - Year 2 with the Medicaid services furnished through FFS - Year 1. | |
| Trend of Medicaid services furnished through FFS from Year 2 to Year 3 | AB | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares Medicaid services furnished through FFS - Year 3 with the Medicaid services furnished through FFS - Year 2. | |
| Change in the number of Medicaid services furnished through FFS from Year 1 to Year 3 | AC | Number (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column calculates Medicaid services furnished through FFS - Year 3 minus the Medicaid services furnished through FFS - Year 1. | |
| Trend of Medicaid services furnished through FFS from Year 1 to Year 3 | AD | Text and percentage change (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column describes the trend of Medicaid services furnished through FFS from Year 1 to Year 3 (auto populated) | |
| Trend of Medicaid services furnished to adult beneficiaries from Year 1 to Year 2 | AE | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares Medicaid services furnished to adult beneficiaries - Year 2 with the Medicaid services furnished to adult beneficiaries - Year 1. | |
| Trend of Medicaid services furnished to adult beneficiaries from Year 2 to Year 3 | AF | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares Medicaid services furnished to adult beneficiaries - Year 3 with the Medicaid services furnished to adult beneficiaries - Year 2. | |
| Change in number of Medicaid services furnished to adult beneficiaries from Year 1 to Year 3 | AG | Number (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column calculates Medicaid services furnished to adult beneficiaries - Year 3 minus Medicaid services furnished to adult beneficiaries - Year 1. | |
| Trend of Medicaid services furnished to adult beneficiaries from Year 1 to Year 3 | AH | Text and percentage change (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column describes the trend of Medicaid services furnished to adult beneficiaries from Year 1 to Year 3. | |
| Trend of Medicaid services furnished to child beneficiaries from Year 1 to Year 2 | AI | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares Medicaid services furnished to child beneficiaries - Year 2 with the Medicaid services furnished to child beneficiaries - Year 1. | |
| Trend of Medicaid services furnished to child beneficiaries from Year 2 to Year 3 | AJ | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares Medicaid services furnished to child beneficiaries - Year 3 with the Medicaid services furnished to child beneficiaries - Year 2. | |
| Change in number of Medicaid services furnished to child beneficiaries from Year 1 to Year 3 | AK | Number (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column calculates Medicaid services furnished to child beneficiaries - Year 3 minus Medicaid services furnished to child beneficiaries - Year 1. | |
| Trend of Medicaid services furnished to child beneficiaries from Year 1 to Year 3 | AL | Text and percentage change (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column describes the trend of Medicaid services furnished to child beneficiaries from Year 1 to Year 3. | |
| Trend of Medicaid services furnished to beneficiaries who are living with disabilities from Year 1 to Year 2 | AM | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares Medicaid services furnished to beneficiaries who are living with disabilities - Year 2 with the Medicaid services furnished to beneficiaries who are living with disabilities - Year 1. | |
| Trend of Medicaid services furnished to beneficiaries who are living with disabilities from Year 2 to Year 3 | AN | Percentage (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column compares Medicaid services furnished to beneficiaries who are living with disabilities - Year 3 with the Medicaid services furnished to beneficiaries who are living with disabilities - Year 2. | |
| Change in number of Medicaid services furnished to beneficiaries who are living with disabilities from Year 1 to Year 3 | AO | Number (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column calculates Medicaid services furnished to beneficiaries who are living with disabilities - Year 3 minus Medicaid services furnished to beneficiaries who are living with disabilities - Year 1. | |
| Trend of Medicaid services furnished to beneficiaries who are living with disabilities from Year 1 to Year 3 | AP | Text and percentage change (auto populated) | The state does not need to enter any data in this column as it is auto populated. This column describes the trend of Medicaid services furnished to beneficiaries who are living with disabilities from Year 1 to Year 3. | |
| Description of trends | AQ | Free text | Enter a description of observed trends for each geographic area over the 3 year period. | |
| Anticipated effect of rate reduction or restructuring | AR | Free text | Provide an estimate of the anticipated effect on the number of Medicaid services furnished through the FFS delivery system in each affected benefit category, by geographic area. | |
VIII. "Addl Concerns " tabs |
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| VIII.A. Summary of access to care concerns or complaints | ||||
| This section allows the state to provide a summary of any access to care concerns or complaints received from beneficiaries, providers, and other interested parties regarding the service(s) for which payment rate reduction or restructuring is proposed along with the responses from the state. The state must populate the requested information in the BEIGE COLORED CELLS in column D. | ||||
| VIII.A.1: The state must summarize any access to care concerns or complaints received from beneficiaries, providers, and other interested parties regarding the services affected by the proposed payment rate reduction or restructuring. | ||||
| VIII.A.2: The state must summarize its responses to any access to care concerns or complaints received from beneficiaries, providers, and other interested parties regarding the services affected by the proposed payment rate reduction or restructuring. | ||||
| VIII.A.3: If additional space is needed, the state may provide information in a separate document and must provide the file name of the document containing additional information and any applicable page numbers. |
| Rate Reduction or Restructuring Template | |
| 1. I hereby certify that, to the best of my knowledge and belief, this report is true, accurate, and complete, and except as noted, has been prepared in accordance with applicable instructions. I further certify that I am familiar with the laws and regulations regarding the documentation of access to care and service payment rates, and this rate reduction or restructuring template is provided in compliance with such laws and regulations. | There appears to be incomplete cells. Please complete both B4 and B5. |
| 2. I am the officer authorized by the relevant state government agency to submit this form, and I have made a good faith effort to ensure that all information reported is true and accurate. | |
| Electronic Signature: | |
| Title & Contact Information: |
| Progress Tracker | |||||||||||||||||
| % Progress to Completion | |||||||||||||||||
| Worksheets | # of Cells Entered Completely * | Required Cells** | % complete (=Col. C / Col. D) |
(% Complete / Worksheet) 0% | 10% | 20% | 30% | 40% | 50% | 60% | 70% | 80% | 90% | 100% | |||
| State Attestation | 0 | 2 | 0% | State Attestation | |||||||||||||
| Summary of Compliance - Section A | 0 | 6 | 0% | Summary of Compliance - Section A | |||||||||||||
| Summary of Compliance - Section C^ | N/A | N/A | N/A | Summary of Compliance - Section C^ | |||||||||||||
| I 80% Medicare | 0 | 1 | 0% | I 80% Medicare | |||||||||||||
| II 4% Aggregate | 0 | 1 | 0% | II 4% Aggregate | |||||||||||||
| III Public Process Attestation | 0 | 2 | 0% | III Public Process Attestation | |||||||||||||
| IV Addl - Analysis | 0 | 3 | 0% | IV Addl - Analysis | |||||||||||||
| V Addl - Providers | 0 | 6 | 0% | V Addl - Providers | |||||||||||||
| VI Addl - Beneficiary | 0 | 8 | 0% | VI Addl - Beneficiary | |||||||||||||
| VII Addl - Services | 0 | 8 | 0% | VII Addl - Services | |||||||||||||
| VIII Addl - Concerns | 0 | 2 | 0% | VIII Addl - Concerns | |||||||||||||
| * Cells that have all the required cells have data entered. Note that it does not check for accuracy of the cell data. | |||||||||||||||||
| ** Cells that require data entry based on current input. | |||||||||||||||||
| ^ This section is only required to complete if Summary of Compliance - Section B says "Met" for all three cells. | |||||||||||||||||
| Per your data entry so far, Table B, Worksheet 0. Summary of Compliance says: | Not Met and/or N/A |
| 0. Summary of compliance with rate reduction or restructuring criteria | You appear to have incomplete cells. Complete cells D6:D11. | ||||
| A. Primary contact information | |||||
| The state will use this section of the tab to provide contact information for any questions regarding the responses provided in this template. The state must populate responses in Column E ("State response") for rows 0.A.1 through 0.A.6. | |||||
| A. Information for primary contact (regarding information reported in this template) | |||||
| # | Item | Data format | State response | ||
| 0.A.1 | Contact Name: | Enter free text | |||
| 0.A.2 | Contact Phone: | Enter number as ###-###-#### | |||
| 0.A.3 | Contact Email: | Enter email address | |||
| 0.A.4 | Contact Title: | Enter free text | |||
| 0.A.5 | State: | Select from set values (drop down) | |||
| 0.A.6 | State Agency Name: | Enter free text | |||
| B. Rate reduction or restructuring criteria | |||||
| The state will use this section of the tab to track whether they have met the rate reduction or restructuring criteria as described in § 447.203(c)(1)(i) through (iii). This section will auto populate with "Met" or "Not Met" based on the information the state provides in the "I 80% Medicare", "II 4% Aggregate", and "III Public Process Attestation" tabs. Additional analyses may be required or requested if all criteria are not met. | |||||
| B. Rate reduction or restructuring criteria | |||||
| Requirements per 42 CFR 447.203(c)(1)(i) through (iii) | |||||
| 0.B.1 | Medicaid payment rates in the aggregate (including base and supplemental payments) following the proposed reduction or restructuring for each benefit category affected by the reduction or restructuring are at or above 80 percent of the most recently published Medicare payment rates for the same or comparable set of Medicare-covered services | § 447.203(c)(1)(i) | N/A | ||
| 0.B.2 | Proposal is likely to result in no more than a 4 percent reduction in aggregate fee-for-service Medicaid expenditures for each benefit category affected by the proposal within the state fiscal year | § 447.203(c)(1)(ii) | N/A | ||
| 0.B.3 | Public processes yielded no significant access to care concerns from beneficiaries, providers, or other interested parties regarding the service(s) for which the payment rate reduction or payment restructuring is proposed, or if such processes did yield concerns, the state can reasonably respond to or mitigate the concerns, as appropriate | § 447.203(c)(1)(iii) | N/A | ||
| C. State's Procedures for Monitoring Continued Compliance | |||||
| If the state meets the rate reduction or restructuring criteria as described in § 447.203(c)(1)(i) through (iii) (i.e., "Met" is reflected in each of rows in Section B. of this tab), the state must describe below its procedures for monitoring continued compliance with section 1902(a)(30)(A), as described in § 447.203(c)(1). Section 1902(a)(30)(A) requires that a state plan for medical assistance must provide such methods and procedures relating to the utilization of, and the payment for, care and services available under the plan (including but not limited to utilization review plans as provided for in section 1903(i)(4)) as may be necessary to safeguard against unnecessary utilization of such care and services and to assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area. | |||||
| C. State's Procedures for Monitoring Continued Compliance | |||||
| # | State response | ||||
| 0.C.1 | No need to complete B23 per responses in cells D16:D18. | ||||
| I. Percentage of Most Recently Published Medicare Payment Rate | |||||||
| A. Initial state analysis for rate reduction or restructuring | |||||||
| The state will use this section of the tab to document if the Medicaid payment rates in the aggregate (including base and supplemental payments) following the proposed rate reduction or restructuring for each benefit category would be at or above 80% of the most recently published Medicare payment rates for the same or comparable set of Medicare-covered services as described in §447.203(c)(1)(i). This rate is auto populated based on the information provided by the state in columns G and H. The state must populate responses in Columns B through F. | |||||||
| Use the beige cell below to indicate the time period of the Medicare payment rates used to compute the individual ratios summed in column E. | Cell A5 is a required field. Please complete cell A5. | ||||||
| # | Name of SPA | Date SPA submitted | Benefit category | Sum of individual ratios | Number of individual ratios | Rate reduction or restructuring percentage |
Rate reduction or restructuring criterion met |
| 0 | Enter the name of the SPA associated with the rate reduction or restructuring | Enter the date the SPA was submitted | Enter the benefit category associated with the rate reduction or restructuring in the SPA. Enter one benefit category per line. | Enter the sum of the individual ratios for individual constituent services within the benefit category. To derive a ratio for individual constituent services, perform a comparison of the Medicaid to the Medicare payment rate on a code-by-code basis, meaning CPT, CDT, or HCPCS, as applicable. Express the sum as a percentage. For example, express the sum of 0.75 and 0.90 as 165%. | Enter the number of ratios contributing to the sum in column E | Auto populated | Auto populated |
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| II. Calculation of Reduction in Aggregate FFS Medicaid Expenditures | |||||||
| A. Aggregate FFS Medicaid expenditures | |||||||
| The state will use this section of the tab to demonstrate whether the proposed reduction or restructuring, including the cumulative effect of all reductions or restructurings taken throughout the current state fiscal year, would be likely to result in no more than a 4 percent reduction in aggregate fee-for-service Medicaid expenditures for each benefit category affected by proposed reduction or restructuring within a state fiscal year as described in §447.203(c)(1)(ii). The state will provide additional information for proposals exceeding this threshold. The expenditures analysis intends to assess how aggregate payments to providers will change as a result of the rate reduction or restructuring, whereas the rate analysis (provided on the "I 80% Medicare" tab) intends to assess how the rates affected by the rate reduction or restructuring will compare to Medicare rates. Payment changes are a function of both the volume of care in the impacted benefit category and other SPAs that may have been implemented during the state's fiscal year. The state must populate responses in Columns E and F. |
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| Use the beige cell below to indicate the time period of the expenditures in column F. | Cell A5 is a required field. Please complete cell A5. | ||||||
| # | Name of SPA | Date SPA submitted | Benefit category | Estimated expenditures | Prior year expenditures | Comparison of expenditures | Rate reduction or restructuring criterion met |
| 0 | Auto populated from the "Name of SPA" entered on the "I 80% Medicare" tab | Auto populated from the "Date SPA submitted" entered on the "I 80% Medicare" tab | Auto populated from the benefit category entered on the "I 80% Medicare" tab | Estimated expenditures AFTER rate reduction or restructuring | Prior year expenditures submitted on the state's Form CMS-64 | Auto populated | Auto populated |
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| III. Medicaid Beneficiary and Provider Input Public Process to Inform Access to Care | |
| The state attests that: - it followed the public processes described in § 447.203(c)(4), - those processes yielded no significant access to care concerns from beneficiaries, providers, or other interested parties regarding the service(s) for which the payment rate reduction or payment restructuring is proposed, - or if such processes did yield concerns, the state can reasonably respond to or mitigate the concerns, as appropriate. The state acknowledges that upon request, it shall provide a summary of any access to care concerns or complaints received through these public processes along with the state's responses. |
There appears to be incomplete cells. Please complete both B3 and B4. |
| Electronic Signature: | |
| Title & Contact Information: |
| IV. Additional Rate Analysis | Cell E5, A9 and B9 are required. Please review and complete all required cells. | |||||||||||
| A. Summary of the proposed payment change | ||||||||||||
| The state will use this section of the tab to provide a summary of the proposed payment change as described in 447.203(c)(2)(i) | ||||||||||||
| # | Item | Item instructions | Data format | State response | ||||||||
| IV.A.1 | A summary of the proposed payment change | Provide a summary of the proposed payment change, including the state's reason for the proposal and a description of any policy purpose for the proposed change, including the cumulative effect of all reductions or restructurings taken throughout the current state fiscal year in aggregate fee-for-service Medicaid expenditures for each benefit category affected by proposed reduction or restructuring within a state fiscal year | Free text | |||||||||
| B. Aggregate rate changes | ||||||||||||
| The state will use this section of the tab to provide information on Medicaid payment rates in the aggregate (including base and supplemental payments) before and after the proposed reduction or restructuring for each affected benefit category, and a comparison of each to the most recently published Medicare payment rates for the same or a comparable set of Medicare-covered services and, as reasonably feasible, to the most recently available payment rates of other health care payers in the state or the geographic area for the same or a comparable set of covered services, as described in 447.203(c)(2)(ii). | ||||||||||||
| Use the beige cell below to indicate the time period of the Medicare payment rates used in column F. | Use the beige cell below to indicate the time period of the other health care payer rates used in column G. | |||||||||||
| # | Benefit category | Sum of the Medicaid payment rates in the aggregate BEFORE rate reduction or restructuring |
Sum of the Medicaid payment rates in the aggregate AFTER rate reduction or restructuring |
Number of Individual Ratios | Sum of the ratios of Medicaid payment rates to the comparable Medicare rate BEFORE rate reduction or restructuring | Sum of the ratios of Medicaid payment rates to the comparable other health care payer rate BEFORE rate reduction or restructuring | Sum of the ratios of Medicaid payment rates to the comparable Medicare rate AFTER rate reduction or restructuring | Sum of the ratios of Medicaid payment rates to the comparable other health care payer rate AFTER rate reduction or restructuring | Average taken of the ratios of Medicaid rates (BEFORE rate reduction or restructuring) to Medicare |
Average taken of the ratios of Medicaid rates (BEFORE rate reduction or restructuring) to health care payer |
Average taken of the ratios of Medicaid rates (AFTER rate reduction or restructuring) to Medicare |
Average taken of the ratios of Medicaid rates (AFTER rate reduction or restructuring) to health care payer |
| 0 | Enter the benefit category associated with the rate reduction or restructuring in the SPA. Enter one benefit category per line. | Enter the dollar ($) value of the sum of the Medicaid fee-for-service payment rates in the benefit category, including any base and supplemental payments for services before rate reduction or restructuring. For example, if there are two rates in the benefit category $100 and $200, enter $300 ($100 + $200). | Enter the dollar ($) value of the sum of the Medicaid fee-for-service payment rates in the benefit category, including any base and supplemental payments for services after rate reduction or restructuring. For example, if there are two rates in the benefit category $50 and $150, enter $200 ($50 + $150). | Enter the number of rates contributing to the sum in columns C or D. For example, if there are two rates in the benefit category, enter 2. | Create a ratio of each Medicaid payment rate BEFORE reduction/restructuring to its comparable Medicare rate and sum the ratios together. For example, if the comparable Medicare payment rates are $150 and $250, respectively, then the ratios are $100/$150 and $200/$250. Enter the sum of these ratios. Express this sum as a percentage (146.67%). | Create a ratio of each Medicaid payment rate BEFORE reduction/restructuring to its comparable health care payer rate and sum the ratios together. For example, if the comparable other payer rates are $200 and $300, respectively, then the ratios are $100/$200 and $200/$300. Enter the sum of these ratios. Express this sum as a percentage (116.67%). | Create a ratio of each Medicaid payment rate AFTER reduction/restructuring to its comparable Medicare rate and sum the ratios together. For example, if the comparable Medicare payment rates are $150 and $250, respectively, then the ratios are $50/$150 and $150/$250. Enter the sum of these ratios. Express this sum as a percentage (93.33%). | Create a ratio of each Medicaid payment rate AFTER reduction/restructuring to its comparable health care payer rate and sum the ratios together. For example, if the comparable other payer rates are $200 and $300, respectively, then the ratios are $50/$200 and $150/$300. Enter the sum of these ratios. Express this sum as a percentage (75%). | Auto populated | Auto populated | Auto populated | Auto populated |
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| 193 | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | ||||||||
| 194 | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | ||||||||
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| 196 | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | ||||||||
| 197 | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | ||||||||
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| 200 | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | ||||||||
| V. Participating Providers | Cells D5:E7 are required. Please review and complete all required cells. | ||||||||||||
| A. Three years preceding the SPA submission date | |||||||||||||
| Per 447.203(c)(2)(iii), the state is required to provide the number of actively participating providers of services in each affected benefit category for each of the three years immediately preceding the SPA submission date. The state will use this section of the tab to define each of the three years immediately preceding the SPA submission date. The state must use the most recent and complete data available. | |||||||||||||
| Item # | Item description | Input format | Start date | End date | |||||||||
| V.A.1 | Year 1 | mm/dd/yyyy | |||||||||||
| V.A.2 | Year 2 | mm/dd/yyyy | |||||||||||
| V.A.3 | Year 3 | mm/dd/yyyy | |||||||||||
| B. Actively participating providers of services | |||||||||||||
| The state will use this section of the tab to provide information on the number of actively participating providers of services in each benefit category affected by the proposed reduction or restructuring for each of the 3 years immediately preceding the SPA submission date, by geographic area, provider type, and site of service, as described in 447.203(c)(2)(iii). For this purpose, an actively participating provider is a provider that is participating in the Medicaid program, and actively seeing and providing services to Medicaid beneficiaries, or accepting Medicaid beneficiaries as new patients. | |||||||||||||
| # | Benefit category | State-specified geographic region |
Provider type | Site of service | Number of actively participating providers - Year 1 | Number of actively participating providers - Year 2 | Number of actively participating providers - Year 3 | Trend from Year 1 to Year 2 | Trend from Year 2 to Year 3 | Change from Year 1 to Year 3 |
Trend from Year 1 to Year 3 | Description of trends | Anticipated effect of rate reduction or restructuring |
| 0 | Auto populated from the benefit category entered on the "IV Addl - Analysis" tab | Enter the state-specified geographic region (for example, county or parish) | Enter the provider type | Enter the site of service | Enter the number of actively participating providers of services for Year 1 | Enter the number of actively participating providers of services for Year 2 | Enter the number of actively participating providers of services for Year 3 | Auto populated | Auto populated | Auto populated | Auto populated | Enter a description of observed trends for each geographic area over the 3 year period. | Provide an estimate of the anticipated effect of the rate reduction or restructuring on the number of actively participating providers in each affected benefit category, for each geographic area |
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| 61 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 62 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 63 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 64 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 65 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 66 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 67 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 68 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 69 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 70 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 71 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 72 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 73 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 74 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 75 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 76 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 77 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 78 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 79 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 80 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 81 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 82 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 83 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 84 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 85 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 86 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 87 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 88 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 89 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 90 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 91 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 92 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 93 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 94 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 95 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 96 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 97 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 98 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 99 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 100 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 101 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 102 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 103 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 104 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 105 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 106 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 107 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 108 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 109 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 110 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 111 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 112 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 113 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 114 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 115 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 116 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 117 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 118 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 119 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 120 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 121 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 122 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 123 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 124 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 125 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 126 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 127 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 128 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 129 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 130 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 131 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 132 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 133 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 134 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 135 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 136 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 137 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 138 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 139 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 140 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 141 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 142 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 143 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 144 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 145 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 146 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 147 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 148 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 149 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 150 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 151 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 152 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 153 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 154 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 155 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 156 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 157 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 158 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 159 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 160 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 161 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 162 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 163 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 164 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 165 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 166 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 167 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 168 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 169 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 170 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 171 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 172 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 173 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 174 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 175 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 176 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 177 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 178 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 179 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 180 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 181 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 182 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 183 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 184 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 185 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 186 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 187 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 188 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 189 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 190 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 191 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 192 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 193 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 194 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 195 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 196 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 197 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 198 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 199 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| 200 | -- | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | ||||||||
| VI. Beneficiaries Receiving Services | |||||||||||||||||||||||||||||||||||||||||
| A. Three years preceding the SPA submission date | Cells D5:E7 and D11:D12 are required fields. Please review section A and B and complete all required cells. | ||||||||||||||||||||||||||||||||||||||||
| Per 447.203(c)(2)(iv), the state must provide the number of beneficiaries receiving services through the FFS delivery system in each affected benefit category for each of the three years immediately preceding the SPA submission date. The state will use this section of the tab to define each of the three years immediately preceding the SPA submission date. The state must use the most recent and complete data available. | |||||||||||||||||||||||||||||||||||||||||
| Item # | Item description | Input format | Start date | End date | |||||||||||||||||||||||||||||||||||||
| VI.A.1 | Year 1 | mm/dd/yyyy | |||||||||||||||||||||||||||||||||||||||
| VI.A.2 | Year 2 | mm/dd/yyyy | |||||||||||||||||||||||||||||||||||||||
| VI.A.3 | Year 3 | mm/dd/yyyy | |||||||||||||||||||||||||||||||||||||||
| B. Beneficiaries receiving services through FFS delivery system | |||||||||||||||||||||||||||||||||||||||||
| The state will use this section of the tab to provide qualitative information on the beneficiaries receiving services, through the FFS delivery system in the benefit categories affected by the proposed reduction or restructuring over the three-year period specified above, as described in 447.203(c)(2)(iv). | |||||||||||||||||||||||||||||||||||||||||
| # | Item | Data format | State response | ||||||||||||||||||||||||||||||||||||||
| VI.B.1 | Describe the demographic characteristics of the beneficiary populations receiving services affected by the rate reduction or restructuring | Free text | |||||||||||||||||||||||||||||||||||||||
| VI.B.2 | Describe how the proposed rate reduction or restructuring may affect access to care and service delivery for beneficiaries in various populations | Free text | |||||||||||||||||||||||||||||||||||||||
| VI.B.3 | If additional space is needed, the state may provide qualitative information in a separate document. The state must provide the file name of the document containing this information and any applicable page numbers. | Attachment | |||||||||||||||||||||||||||||||||||||||
| C. Beneficiaries receiving services through FFS delivery system | |||||||||||||||||||||||||||||||||||||||||
| The state will use this section of the tab to provide quantitative information on the beneficiaries receiving services through the FFS delivery system in the benefit categories affected by the proposed reduction or restructuring for each of the three years immediately preceding the SPA submission date by geographic area, including the number and proportion of beneficiaries who are adults and children and who are living with disabilities, as described in 447.203(c)(2)(iv). | |||||||||||||||||||||||||||||||||||||||||
| # | Benefit category | State-specified geographic region | Total number of beneficiaries receiving services - Year 1 | Total number of beneficiaries receiving services - Year 2 | Total number of beneficiaries receiving services - Year 3 | Number of adult beneficiaries receiving services - Year 1 | Number of adult beneficiaries receiving services - Year 2 | Number of adult beneficiaries receiving services - Year 3 | Number of child beneficiaries receiving services - Year 1 | Number of child beneficiaries receiving services - Year 2 | Number of child beneficiaries receiving services - Year 3 | Number of beneficiaries who are living with disabilities receiving services - Year 1 | Number of beneficiaries who are living with disabilities receiving services - Year 2 | Number of beneficiaries who are living with disabilities receiving services - Year 3 | Proportion of beneficiaries who are adults - Year 1 | Proportion of beneficiaries who are adults - Year 2 | Proportion of beneficiaries who are adults - Year 3 | Proportion of beneficiaries who are children - Year 1 | Proportion of beneficiaries who are children - Year 2 | Proportion of beneficiaries who are children - Year 3 | Proportion of beneficiaries who are living with disabilities - Year 1 | Proportion of beneficiaries who are living with disabilities - Year 2 | Proportion of beneficiaries who are living with disabilities - Year 3 | Trend of total number of beneficiaries receiving services from Year 1 to Year 2 | Trend of total number of beneficiaries receiving services from Year 2 to Year 3 | Change in total number of beneficiaries receiving services from Year 1 to Year 3 | Trend of total number of beneficiaries receiving services from Year 1 to Year 3 | Trend of number of adult beneficiaries receiving services from Year 1 to Year 2 | Trend of number of adult beneficiaries receiving services from Year 2 to Year 3 | Change in number of adult beneficiaries receiving services from Year 1 to Year 3 | Trend of number of adult beneficiaries receiving services from Year 1 to Year 3 | Trend of number of child beneficiaries receiving services from Year 1 to Year 2 | Change in number of child beneficiaries receiving services from Year 2 to Year 3 | Change in number of child beneficiaries receiving services from Year 1 to Year 3 | Trend of number of child beneficiaries receiving services from Year 1 to Year 3 | Trend of number of beneficiaries who are living with disabilities receiving services from Year 1 to Year 2 | Trend of number of beneficiaries who are living with disabilities receiving services from Year 2 to Year 3 | Change in number of beneficiaries who are living with disabilities receiving services from Year 1 to Year 3 | Trend of number of beneficiaries who are living with disabilities receiving services from Year 1 to Year 3 | Description of trends | Anticipated effect of rate reduction or restructuring |
| 0 | Auto populated from the benefit category entered on the "IV Addl - Analysis" tab | Enter the state-specified geographic region (for example, county or parish) | Enter the total number of beneficiaries receiving services for Year 1 | Enter the total number of beneficiaries receiving services for Year 2 | Enter the total number of beneficiaries receiving services for Year 3 | Enter the number of adult beneficiaries receiving services for Year 1 | Enter the number of adult beneficiaries receiving services for Year 2 | Enter the number of adult beneficiaries receiving services for Year 3 | Enter the number of child beneficiaries receiving services for Year 1 | Enter the number of child beneficiaries receiving services for Year 2 | Enter the number of child beneficiaries receiving services for Year 3 | Enter the number of beneficiaries who are living with disabilities receiving services for Year 1 | Enter the number of beneficiaries who are living with disabilities receiving services for Year 2 | Enter the number of beneficiaries who are living with disabilities receiving services for Year 3 | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Enter a description of observed trends for each geographic area over the 3 year period. | Provide an estimate of the anticipated effect of the rate reduction or restructuring on the number beneficiaries receiving services in each affected benefit category, for each geographic area |
| 1 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 2 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 3 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 4 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 5 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 6 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 7 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 8 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 9 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 10 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
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| 163 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 164 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 165 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
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| 170 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
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| 172 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 173 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 174 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 175 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 176 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 177 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 178 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 179 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 180 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
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| 182 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 183 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 184 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 185 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 186 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 187 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 188 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 189 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 190 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 191 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 192 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 193 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 194 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 195 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 196 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 197 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 198 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 199 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| 200 | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | |||||||||||||||
| VII. Medicaid Services | |||||||||||||||||||||||||||||||||||||||||||
| A. Three years preceding the SPA submission date | Cells D5:E7 and D11:D12 are required fields. Please review and complete all required cells. | ||||||||||||||||||||||||||||||||||||||||||
| Per 447.203(c)(2)(v), the state must provide the number of Medicaid services furnished through the FFS delivery system in each affected benefit category for each of the three years immediately preceding the SPA submission date. The state will use this section of the tab to define each of the three years immediately preceding the SPA submission date. The state must use the most recent and complete data available. | |||||||||||||||||||||||||||||||||||||||||||
| Item # | Item description | Input format | Start date | End date | |||||||||||||||||||||||||||||||||||||||
| VII.A.1 | Year 1 | mm/dd/yyyy | |||||||||||||||||||||||||||||||||||||||||
| VII.A.2 | Year 2 | mm/dd/yyyy | |||||||||||||||||||||||||||||||||||||||||
| VII.A.3 | Year 3 | mm/dd/yyyy | |||||||||||||||||||||||||||||||||||||||||
| B. Medicaid services furnished through FFS delivery system | |||||||||||||||||||||||||||||||||||||||||||
| The state will use this section of the tab to provide qualitative information on services furnished through the FFS delivery system in the benefit categories affected by the proposed reduction or restructuring over the three-year period specified above, as described in 447.203(c)(2)(v). | |||||||||||||||||||||||||||||||||||||||||||
| # | Item | Data format | State response | ||||||||||||||||||||||||||||||||||||||||
| VII.B.1 | Describe services affected by the rate reduction or restructuring | Free text | |||||||||||||||||||||||||||||||||||||||||
| VII.B.2 | Describe how the proposed rate reduction or restructuring may affect access to care and service delivery. | Free text | |||||||||||||||||||||||||||||||||||||||||
| VII.B.3 | If additional space is needed, the state may provide qualitative information in a separate document. The state must provide the file name of the document containing this information and any applicable page numbers. | Attachment | |||||||||||||||||||||||||||||||||||||||||
| C. Medicaid services furnished through FFS delivery system | |||||||||||||||||||||||||||||||||||||||||||
| The state will use this section of the tab to provide quantitative information on services furnished through the FFS delivery system in the benefit categories affected by the proposed reduction or restructuring for each of the three years immediately preceding the SPA submission date, by geographic area, provider type, and site of service, including information about the number and proportion of Medicaid services furnished to adults and children and beneficiaries living with disabilities, as described in 447.203(c)(2)(v). | |||||||||||||||||||||||||||||||||||||||||||
| # | Benefit category | State-specified geographic region | Provider type | Site of service | Number of Medicaid services furnished through FFS - Year 1 | Number of Medicaid services furnished through FFS - Year 2 | Number of Medicaid services furnished through FFS - Year 3 | Number of Medicaid services furnished to adult beneficiaries - Year 1 | Number of Medicaid services furnished to adult beneficiaries - Year 2 | Number of Medicaid services furnished to adult beneficiaries - Year 3 | Number of Medicaid services furnished to child beneficiaries - Year 1 | Number of Medicaid services furnished to child beneficiaries - Year 2 | Number of Medicaid services furnished to child beneficiaries - Year 3 | Number of Medicaid services furnished to beneficiaries who are living with disabilities - Year 1 | Number of Medicaid services furnished to beneficiaries who are living with disabilities - Year 2 | Number of Medicaid services furnished to beneficiaries who are living with disabilities - Year 3 | Proportion of Medicaid services furnished to adult beneficiaries - Year 1 | Proportion of Medicaid services furnished to adult beneficiaries - Year 2 | Proportion of Medicaid services furnished to adult beneficiaries - Year 3 | Proportion of Medicaid services furnished to child beneficiaries - Year 1 | Proportion of Medicaid services furnished to child beneficiaries - Year 2 | Proportion of Medicaid services furnished to child beneficiaries - Year 3 | Proportion of Medicaid services furnished to beneficiaries living with disabilities - Year 1 | Proportion of Medicaid services furnished to beneficiaries living with disabilities - Year 2 | Proportion of Medicaid services furnished to beneficiaries living with disabilities - Year 3 | Trend of Medicaid services furnished through FFS from Year 1 to Year 2 | Trend of Medicaid services furnished through FFS from Year 2 to Year 3 | Change in the number of Medicaid services furnished through FFS from Year 1 to Year 3 | Trend of Medicaid services furnished through FFS from Year 1 to Year 3 | Trend of Medicaid services furnished to adult beneficiaries from Year 1 to Year 2 | Trend of Medicaid services furnished to adult beneficiaries from Year 2 to Year 3 | Change in number of Medicaid services furnished to adult beneficiaries from Year 1 to Year 3 | Trend of Medicaid services furnished to adult beneficiaries from Year 1 to Year 3 | Trend of Medicaid services furnished to child beneficiaries from Year 1 to Year 2 | Trend of Medicaid services furnished to child beneficiaries from Year 2 to Year 3 | Change in number of Medicaid services furnished to child beneficiaries from Year 1 to Year 3 | Trend of Medicaid services furnished to child beneficiaries from Year 1 to Year 3 | Trend of Medicaid services furnished to beneficiaries who are living with disabilities from Year 1 to Year 2 | Trend of Medicaid services furnished to beneficiaries who are living with disabilities from Year 2 to Year 3 | Change in number of Medicaid services furnished to beneficiaries who are living with disabilities from Year 1 to Year 3 | Trend of Medicaid services furnished to beneficiaries who are living with disabilities from Year 1 to Year 3 | Description of trends | Anticipated effect of rate reduction or restructuring |
| 0 | Auto populated from the benefit category entered on the "IV Addl - Analysis" tab | Auto populated from the state-specified geographic region used on the "Addl - Providers" tab | Auto populated from the provider type used on the "Addl - Providers" tab | Auto populated from the site of service used on the "Addl - Providers" tab | Enter the total number Medicaid services furnished through FFS for Year 1 | Enter the total number Medicaid services furnished through FFS for Year 2 | Enter the total number Medicaid services furnished through FFS for Year 3 | Enter the number of Medicaid services furnished to adult beneficiaries for Year 1 | Enter the number of Medicaid services furnished to adult beneficiaries for Year 2 | Enter the number of Medicaid services furnished to adult beneficiaries for Year 3 | Enter the number of Medicaid services furnished to child beneficiaries for Year 1 | Enter the number of Medicaid services furnished to child beneficiaries for Year 2 | Enter the number of Medicaid services furnished to child beneficiaries for Year 3 | Enter the number of Medicaid services furnished to beneficiaries who are living with disabilities for Year 1 | Enter the number of Medicaid services furnished to beneficiaries who are living with disabilities for Year 2 | Enter the number of Medicaid services furnished to beneficiaries who are living with disabilities for Year 3 | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Auto populated | Enter a description of observed trends for each geographic area over the 3 year period. | Provide an estimate of the anticipated effect on the number of Medicaid services furnished through the FFS delivery system in each affected benefit category, for each geographic area |
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| 18 | -- | -- | -- | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0 | #DIV/0! | #DIV/0! | #DIV/0! | 0 | #DIV/0! | ||||||||||||||
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| 21 | -- | -- | -- | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0 | #DIV/0! | #DIV/0! | #DIV/0! | 0 | #DIV/0! | ||||||||||||||
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| 28 | -- | -- | -- | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0 | #DIV/0! | #DIV/0! | #DIV/0! | 0 | #DIV/0! | ||||||||||||||
| 29 | -- | -- | -- | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0 | #DIV/0! | #DIV/0! | #DIV/0! | 0 | #DIV/0! | ||||||||||||||
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| 31 | -- | -- | -- | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0 | #DIV/0! | #DIV/0! | #DIV/0! | 0 | #DIV/0! | ||||||||||||||
| 32 | -- | -- | -- | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0 | #DIV/0! | #DIV/0! | #DIV/0! | 0 | #DIV/0! | ||||||||||||||
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| 36 | -- | -- | -- | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0 | #DIV/0! | #DIV/0! | #DIV/0! | 0 | #DIV/0! | ||||||||||||||
| 37 | -- | -- | -- | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0 | #DIV/0! | #DIV/0! | #DIV/0! | 0 | #DIV/0! | ||||||||||||||
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| 40 | -- | -- | -- | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0 | #DIV/0! | #DIV/0! | #DIV/0! | 0 | #DIV/0! | ||||||||||||||
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| 42 | -- | -- | -- | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0 | #DIV/0! | #DIV/0! | #DIV/0! | 0 | #DIV/0! | ||||||||||||||
| 43 | -- | -- | -- | -- | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0.0 | #DIV/0! | #DIV/0! | #DIV/0! | 0 | #DIV/0! | #DIV/0! | #DIV/0! | 0 | #DIV/0! | ||||||||||||||
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| VIII. Summary of Access to Care Concerns or Complaints | |||
| A. Summary of access to care concerns or complaints | |||
| The state will use this section of the tab to provide a summary of any access to care concerns or complaints received from beneficiaries, providers, and other interested parties regarding the service(s) for which the payment rate reduction or restructuring is proposed, as described in 447.203(c)(2)(vi). The state must also include its response to these concerns. | Cells D5:D6 are required fields. Please review cells D5:D6 and complete all cells. | ||
| # | Item | Data format | State response |
| VIII.A.1 | Summary of any access to care concerns or complaints received from beneficiaries, providers, or other interested parties regarding the services affected by the proposed payment rate reduction or restructuring. | Free text | |
| VIII.A.2 | Summary of the state's response to any access to care concerns or complaints received from beneficiaries, providers, and other interested parties regarding the services affected by the proposed payment rate reduction or restructuring. | Free text | |
| VIII.A.3 | If additional space is needed, the state may provide information in a separate document. The state must provide the file name of the document containing this information and any applicable page numbers. | Attachment | |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |