| This tab describes the differences between the template published on Medicaid.gov on July 9, 2024 and the template posted for public comment on November 19, 2025. | |||
| Worksheet | Cell Reference in "2025_09_19_Template_with_Tracked_Changes.xlsx" | Description of Change | Changes to Text in Blue |
| All worksheets | After all the following changes were implemented, additional formatting changes were made for 508 conformance. The file "2025_09_19_Template_Clean_Unlocked_508_Conformant.xlsx" reflects all the changes listed in this workbook as well as the changes for 508 conformance. | 508 conformance | N/A |
| PRA Disclosure Statement | A1 | Made background white for consistency with other tabs | N/A |
| Overview | B3 | Edits to text | As described at 42 CFR 447.203 and 447.204, implementing section 1902(a)(30)(A) of the Social Security Act (the Act), a state is 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 doesdo not meet the requirements in 42 CFR 447.203(c)(1). The information in this template will be reviewed as part of the Sstate plan amendment (SPA) review process. |
| Overview | B6 | Edits to text | - 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 state plan amendment (SPA). - Questions about this form may be directed to MedicaidAccesstoCare@cms.hhs.gov. |
| Overview | C9 | Edits to text and made the word "blue" blue. | 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 fee-for-service 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 Ccompliance" tab (2) "I 80% Medicare" tab (3) "II 4% aAggregate" 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: |
| Overview | D11 | Edits to text | Attestation that the template is true, accurate, and complete, and has been prepared in accordance with applicable instructions |
| Overview | D12 | Edits to text | 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 |
| Overview | D13 | Edits to text | Details related to the aggregate Medicaid rate and comparison to Medicare rate to ensure the proposed rate reduction or restructuring is at or above 80% of the most recently published Medicare payment rates 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 |
| Overview | D14 | Edits to text | Comparison of estimated aggregate expenditures after proposed rate reductions or restructuring and prior years' expenditures |
| Instructions | B3 | Edits to text | 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. |
| Instructions | B4 | Capitalization | Instructions for Information Required for All State Plan Amendments Proposing Rate Reduction or Restructuring |
| Instructions | C7 | Removed capitalization | 0.A. Information for Primary Contact Primary contact information |
| Instructions | C9 | Edits to text | 0.A.5: The state must select the relevant state or territory name from the drop down for the name of the state/territory agency that is submitting this report. |
| Instructions | C10 | Edits to text | 0.A.6: The state must enter the state/territory agency that is submitting this report. |
| Instructions | C11 | Centered alignment and made row heights consistent in this section. | N/A |
| Instructions | C12 | Edits to text | 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% aAggregate" 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. |
| Instructions | C14 | Edits to text | 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." |
| Instructions | C16 | Inserted new row | 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). |
| Instructions | C18 | Removed capitalization | I.A. Initial state analysis for rate reduction or restructuring |
| Instructions | C19 | Edits to text | 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. |
| Instructions | E21 | Removed capitalization | Data format |
| Instructions | F21 | Removed capitalization | Instructions and definition |
| Instructions | F24 | Edits to text | Enter the type of service benefit category associated with the rate reduction or restructuring in the SPA Medicaid payment rate (e.g., primary care services, obstetrical and gynecological services, behavioral health outpatient services, home and community based services). |
| Instructions | C25 | Edits to text | |
| Instructions | E25 | Edits to text | Dollar amount Percentage |
| Instructions | F25 | Edits to text | Enter the Medicaid payment rates for the benefit category in the aggregate (including base and supplemental payments) AFTER the rate reduction or restructuring 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 the beige cell above the column to indicate the time period of the Medicare payment rates used to compute the individual ratios summed in column E. |
| Instructions | C26 | Edits to text | |
| Instructions | E26 | Edits to text | |
| Instructions | F26 | Edits to text | Enter the most recently published Medicare payment rates for the benefit category in aggregate. Enter the number of ratios contributing to the sum in column E. |
| Instructions | F27 | Edits to text | 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 aggregated Medicaid payment rate compared to the Medicare payment rate entered by the state. |
| Instructions | C31 | Edits to text | 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 Nno 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 B through F. |
| Instructions | E33 | Removed capitalization | Data format |
| Instructions | F33 | Removed capitalization | Instructions and definition |
| Instructions | F37 | Edits to text | Enter estimated expenditures AFTER rate reduction or restructuring. |
| Instructions | F38 | Edits to text | Enter prior year expenditures submitted on the state's Form CMS-64. Use the beige cell above the column to indicate the time period of the expenditures. |
| Instructions | F39 | Edits to text | 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 |
| Instructions | C42 | Edits to text | 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). |
| Instructions | B43 | Edits to text | Additional Analyses (to be completed if the state SPA does not meet any of the three criteria, as shown in tabs I through III) |
| Instructions | B44 | Edits to text | For any state 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. |
| Instructions | C47 | Edits to text | 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. reason for the proposal, a description of any policy purpose for the proposed change, and the cumulative effect of all reductions or restructurings taken throughout the current state fiscal year in aggregate for fee-for-service Medicaid expenditures for each benefit category affected by proposed reduction or restructuring within a state fiscal year. |
| Instructions | C49 | Edits to text | 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. additional details about the aggregate rate changes in the proposed rate reduction or restructuring. The state must populate the requested information in the BEIGE COLORED CELLS in columns B through I. |
| Instructions | E51 | Removed capitalization | Data format |
| Instructions | F51 | Removed capitalization | Instructions and definition |
| Instructions | F52 | Edits to text | Enter the benefit category type of service associated with the rate reduction or restructuring in the SPA. Medicaid payment rate (e.g., primary care services, obstetrical and gynecological services, behavioral health outpatient services, home and community based services). |
| Instructions | C53 | Replaced text | Sum of the Medicaid payment rates in the aggregate BEFORE rate reduction or restructuring |
| Instructions | C54 | Replaced text | Sum of the Medicaid payment rates in the aggregate AFTER rate reduction or restructuring |
| Instructions | C55 | Replaced text | Number of Individual Ratios |
| Instructions | C56 | Replaced text | Sum of the ratios of Medicaid payment rates to the comparable Medicare rate BEFORE rate reduction or restructuring |
| Instructions | C57 | Replaced text | Sum of the ratios of Medicaid payment rates to the comparable other health care payer rate BEFORE rate reduction or restructuring |
| Instructions | C58 | Replaced text | Sum of the ratios of Medicaid payment rates to the comparable Medicare rate AFTER rate reduction or restructuring |
| Instructions | C59 | Replaced text | Sum of the ratios of Medicaid payment rates to the comparable other health care payer rate AFTER rate reduction or restructuring |
| Instructions | C60 | Replaced text | Average taken of the ratios of Medicaid rates (BEFORE rate reduction or restructuring) to Medicare |
| Instructions | C61 | Replaced text | Average taken of the ratios of Medicaid rates (BEFORE rate reduction or restructuring) to health care payer |
| Instructions | C62 | Replaced text | Average taken of the ratios of Medicaid rates (AFTER rate reduction or restructuring) to Medicare |
| Instructions | C63 | Replaced text | Average taken of the ratios of Medicaid rates (AFTER rate reduction or restructuring) to health care payer |
| Instructions | E53 | Replaced text | Dollar |
| Instructions | E54 | Replaced text | Dollar |
| Instructions | E55 | Replaced text | Number |
| Instructions | E56 | Replaced text | Percentage |
| Instructions | E57 | Replaced text | Percentage |
| Instructions | E58 | Replaced text | Percentage |
| Instructions | E59 | Replaced text | Percentage |
| Instructions | E60 | Replaced text | Percentage (auto populated) |
| Instructions | E61 | Replaced text | Percentage (auto populated) |
| Instructions | E62 | Replaced text | Percentage (auto populated) |
| Instructions | E63 | Replaced text | Percentage (auto populated) |
| Instructions | F53 | Replaced text | Enter the dollar ($) value of the sum of the Medicaid fee-for-service payment rates in the benefit category, including any base and supplemental payments for services before rate reduction or restructuring. |
| Instructions | F54 | Replaced text | Enter the dollar ($) 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. |
| Instructions | F55 | Replaced text | Enter the number of rates contributing to the sum in columns C or D. |
| Instructions | F56 | Replaced text | 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 the beige cell above the column to indicate the time period of the Medicare payment rates used to compute the individual ratios. |
| Instructions | F57 | Replaced text | 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 the beige cell above the column to indicate the time period of the other health care payer rates used to compute the individual ratios. |
| Instructions | F58 | Replaced text | 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. |
| Instructions | F59 | Replaced text | 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. |
| Instructions | F60 | Replaced text | 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. |
| Instructions | F61 | Replaced text | 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. |
| Instructions | F62 | Replaced text | 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. |
| Instructions | F63 | Replaced text | 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 |
| Instructions | C69 | Edits to text | 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. |
| Instructions | E71 | Removed capitalization | Data format |
| Instructions | F71 | Removed capitalization | Instructions and definition |
| Instructions | F74 | Edits to 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. [PLACEHOLDER FOR ADDITIONAL INSTRUCTIONS RELATED TO PROVIDER TYPE] |
| Instructions | F75 | Edits to 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. [PLACEHOLDER FOR ADDITIONAL INSTRUCTIONS RELATED TO SITE OF SERVICE] |
| Instructions | F76 | Edits to text | 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 |
| Instructions | F77 | Edits to text | 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 |
| Instructions | F78 | Edits to text | 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 |
| Instructions | F79 | Edits to text | 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 / N with the number of actively participating providers - Year 1. (auto populated) |
| Instructions | F80 | Edits to text | 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 / N with the number of actively participating providers - Year 2. (auto populated) |
| Instructions | F81 | Edits to text | 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 - N minus the number of actively participating providers - Year 1. (auto populated) |
| Instructions | F82 | Edits to text | The state does not need to enter any data in this column as it is auto populated. This column describes description of the trend of the number of actively participating providers from Year 1 to Year 3. (auto populated) |
| Instructions | F84 | Edits to 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 for each geographic area. |
| Instructions | C85 | Edits to text | VI. "Addl - Beneficiary" tab |
| Instructions | C90 | Edits to text | 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. |
| Instructions | C93 | Edits to text | 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. |
| Instructions | C96 | Edits to text | 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 subject to the proposed payment rate reduction or payment restructuring for each affected benefit category. The state must populate the requested information in the BEIGE COLORED CELLS in columns C through O and columns AO through AP. |
| Instructions | E98 | Removed capitalization | Data format |
| Instructions | F98 | Removed capitalization | Instructions and definition |
| Instructions | F110 | Edits to text | 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. |
| Instructions | F111 | Edits to text | 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. |
| Instructions | F112 | Edits to text | 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. |
| Instructions | F113 | Edits to text | |
| Instructions | F114 | Edits to text | |
| Instructions | F115 | Edits to text | |
| Instructions | F116 | Edits to text | |
| Instructions | F117 | Edits to text | |
| Instructions | F118 | Edits to text | |
| Instructions | F119 | Edits to text | |
| Instructions | F120 | Edits to text | |
| Instructions | F121 | Edits to text | |
| Instructions | F122 | Edits to text | 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 / T with the total number of beneficiaries receiving services - Year 1. (auto populated) |
| Instructions | F123 | Edits to text | 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 / T with the total number of beneficiaries receiving services - Year 2. (auto populated) |
| Instructions | F124 | Edits to text | 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. (auto populated) |
| Instructions | F125 | Edits to text | The state does not need to enter any data in this column as it is auto populated. This column describes Description of the trend of total number of beneficiaries receiving services from Year 1 to Year 3. (auto populated) |
| Instructions | F126 | Edits to text | 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 / N with the number of adult beneficiaries receiving services - Year 1. (auto populated) |
| Instructions | F127 | Edits to text | 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 / N with the number of adult beneficiaries receiving services - Year 2 (auto populated) |
| Instructions | F128 | Edits to text | 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. (auto populated) |
| Instructions | F129 | Edits to text | The state does not need to enter any data in this column as it is auto populated. This column describes Description of the trend of the number of adult beneficiaries receiving services from Year 1 to Year 3. (auto populated) |
| Instructions | F130 | Edits to text | 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 / N with the number of child beneficiaries receiving services - Year 1. (auto populated) |
| Instructions | F131 | Edits to text | 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 / N with the number of child beneficiaries receiving services - Year 2. (auto populated) |
| Instructions | F132 | Edits to text | 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. (auto populated) |
| Instructions | F133 | Edits to text | The state does not need to enter any data in this column as it is auto populated. This column describes Description of the trend of the number of child beneficiaries receiving services from Year 1 to Year 3. (auto populated) |
| Instructions | F134 | Edits to text | 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 / N with the number of beneficiaries who are living with disabilities receiving services - Year 1. (auto populated) |
| Instructions | F135 | Edits to text | 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 / N with the number of beneficiaries who are living with disabilities receiving services - Year 2. (auto populated) |
| Instructions | F136 | Edits to text | 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 - N minus the number of beneficiaries who are living with disabilities receiving services - Year 1. (auto populated) |
| Instructions | F137 | Edits to text | The state does not need to enter any data in this column as it is auto populated. This column describes Description of the trend of the number of beneficiaries who are living with disabilities receiving services from Year 1 to Year 3. (auto populated) |
| Instructions | F138 | Edits to text | Enter a description of observed trends for each geographic area over the 3 year period. |
| Instructions | F139 | Edits to 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 for each geographic area |
| Instructions | C131 | Edits to text | Change in Trend of number of child beneficiaries receiving services from Year 2 to Year 3 |
| Instructions | C135 | Edits to text | Trend of number of beneficiaries who are living with disabilities receiving services from Year 12 to Year 23 |
| Instructions | C145 | Edits to text | 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 for each benefit category. The state must populate the requested information in the BEIGE COLORED CELLS in column D. |
| Instructions | C148 | Edits to text | 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. |
| Instructions | C151 | Edits to text | 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, for each benefit category. The state must include the count of claims for the services subject to the proposed payment rate reduction or payment restructuring for each affected benefit category. The state must populate the requested information in the BEIGE COLORED CELLS in columns CF through Q and columns AQ through AR. |
| Instructions | C153 | Removed extra spaces in row names in this column | N/A |
| Instructions | E153 | Removed capitalization | Data format |
| Instructions | F153 | Removed capitalization | Instructions and definition |
| Instructions | F157 | Edits to text | Auto populated from the site of service used on the "Addl - Providers" tab |
| Instructions | F170 | Edits to text | |
| Instructions | F171 | Edits to text | |
| Instructions | F172 | Edits to text | |
| Instructions | F173 | Edits to text | |
| Instructions | F174 | Edits to text | |
| Instructions | F175 | Edits to text | |
| Instructions | F176 | Edits to text | |
| Instructions | F177 | Edits to text | |
| Instructions | F178 | Edits to text | |
| Instructions | F179 | Edits to text | 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. (auto populated) |
| Instructions | F180 | Edits to text | 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. (auto populated) |
| Instructions | F181 | Edits to text | 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. (auto populated) |
| Instructions | F182 | Edits to text | The state does not need to enter any data in this column as it is auto populated. This column describes Description of the trend of Medicaid services furnished through FFS from Year 1 to Year 3 (auto populated) |
| Instructions | F183 | Edits to text | 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. (auto populated) |
| Instructions | F184 | Edits to text | 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. (auto populated) |
| Instructions | F185 | Edits to text | 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. (auto populated) |
| Instructions | F186 | Edits to text | The state does not need to enter any data in this column as it is auto populated. This column describes Description of the trend of Medicaid services furnished to adult beneficiaries from Year 1 to Year 3. (auto populated) |
| Instructions | F187 | Edits to text | 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. (auto populated) |
| Instructions | F188 | Edits to text | 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. (auto populated) |
| Instructions | F189 | Edits to text | 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. (auto populated) |
| Instructions | F190 | Edits to text | The state does not need to enter any data in this column as it is auto populated. This column describes Description of the trend of Medicaid services furnished to child beneficiaries from Year 1 to Year 3. (auto populated) |
| Instructions | F191 | Edits to text | 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. (auto populated) |
| Instructions | F192 | Edits to text | 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. (auto populated) |
| Instructions | F193 | Edits to text | 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. (auto populated) |
| Instructions | F194 | Edits to text | The state does not need to enter any data in this column as it is auto populated. This column describes Description of the trend of Medicaid services furnished to beneficiaries who are living with disabilities from Year 1 to Year 3. (auto populated) |
| Instructions | F196 | Edits to 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 for each geographic area. |
| Instructions | C176 | Edits to text | Proportion of Medicaid services furnished to beneficiaries living with disabilities - Year 1 |
| Instructions | C177 | Edits to text | Proportion of Medicaid services furnished to beneficiaries living with disabilities - Year 2 |
| Instructions | C178 | Edits to text | Proportion of Medicaid services furnished to beneficiaries living with disabilities - Year 3 |
| Instructions | C181 | Edits to text | Change in the number of Medicaid services furnished through FFS from Year 1 to Year 3 |
| Instructions | C199 | Edits to text | 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) impacted by for which the proposed the 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. |
| Instructions | C201 | Edits to text | VIII.A.2: The state must summarize its provide the responses provided 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. |
| Instructions | C202 | Edits to text | 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. |
| State Attestation | A4 | Edits to text (added comma) | 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. |
| 0 Summary of compliance | A4 | Edits to text | The state will use this section of the tab to provide contact information for any questions regarding thisthe responses provided in this template. The state must populate responses in Column E ("State response") for rows 0.A.1 through 0.A.6. |
| 0 Summary of compliance | A5 | Removed capitalization | A. Information for primary contact (regarding information reported in this template) |
| 0 Summary of compliance | D7 | Removed capitalization | Data format |
| 0 Summary of compliance | A17 | Edits to text | 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% Aaggregate", and "III Public Process Attestation" tabs. Additional analyses may be required or requested if all criteria are not met. |
| 0 Summary of compliance | A18 | Removed capitalization | B. Rate reduction or restructuring criteria |
| 0 Summary of compliance | B20 | Edits to text | 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 |
| 0 Summary of compliance | B21 | Edits to text | Proposal will 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 duringwithin the state fiscal year |
| 0 Summary of compliance | A25 | Added text | C. State's Procedures for Monitoring Continued Compliance |
| 0 Summary of compliance | A26 | Added text | 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. |
| 0 Summary of compliance | A27 | Added text | C. State's Procedures for Monitoring Continued Compliance |
| 0 Summary of compliance | A29 | Added text | # |
| 0 Summary of compliance | B29 | Added text | State response |
| 0 Summary of compliance | A30 | Added text | 0.C.1 |
| 0 Summary of compliance | B30 | Added state entry cell | |
| I 80% Medicare | A1 | Capitalization | I. Percentage of Most Recently Published Medicare Payment Rate |
| I 80% Medicare | A4 | Removed capitalization | A. Initial state analysis for rate reduction or restructuring |
| I 80% Medicare | A5 | Edits to text | 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 is 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. |
| I 80% Medicare | E6 | Added instructions for data entry for additional data element | 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. |
| I 80% Medicare | E7 | Added beige cell for data entry | N/A |
| I 80% Medicare | D8 | Removed capitalization | Benefit category |
| I 80% Medicare | E8 | Changed data element to reflect preamble language | |
| I 80% Medicare | F8 | Changed data element to reflect preamble language | |
| I 80% Medicare | E9 | Changed data element to reflect preamble language | Medicaid payment rates for the benefit category in the aggregate (including base and supplemental payments) AFTER rate reduction or restructuring 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%. |
| I 80% Medicare | F9 | Changed data element to reflect preamble language | Most recently published Medicare payment rates for the benefit category in aggregate Enter the number of ratios contributing to the sum in column E |
| I 80% Medicare | G9 | Edits to text | Aggregated Medicaid payment rate/ Medicare payment rate (Auto populated) |
| II 4% Aggregate | A1 | Capitalization | II. Calculation of Reduction in Aggregate FFS Medicaid Expenditures |
| II 4% Aggregate | A4 | Edits to text | 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. |
| II 4% Aggregate | B8 | Edits to text | Auto populated from the "Name of SPA" entered on the "I 80% Medicare" tab |
| II 4% Aggregate | F5 | Added instructions for data entry for additional data element | Use the beige cell below to indicate the time period of the expenditures in column F. |
| II 4% Aggregate | F6 | Added beige cell for data entry | N/A |
| II 4% Aggregate | D7 | Removed capitalization | Benefit Ccategory |
| II 4% Aggregate | C8 | Removed capitalization | Auto populated from the "Date SPA submitted" entered on the "I 80% Medicare" tab |
| II 4% Aggregate | G8 | Edits to text | |
| III Public Process Attestation | A1 | Capitalization | III. Medicaid Beneficiary and Provider Input Public Process to Inform Access to Care |
| III Public Process Attestation | A3 | Edits to text (added commas) | 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. |
| IV Addl - Analysis | A4 | Edits to text | The state will use this section of the tab to provide a summary of the proposed payment change for services as described in 447.203(c)(2)(i) |
| IV Addl - Analysis | C5 | Removed capitalization | Item instructions |
| IV Addl - Analysis | D5 | Removed capitalization | Data format |
| IV Addl - Analysis | C6 | Edits to text | Provide a summary of the proposed payment change, includingDescribe the state's reason for the proposal and a description of any policy purpose for the proposed change, including. Include 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 Addl - Analysis | A10 | Edits to text | 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, Medicaid payment rates change for services 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). |
| IV Addl - Analysis | E10 | Added instructions for data entry for additional data element | Use the beige cell below to indicate the time period of the Medicare payment rates in column E. |
| IV Addl - Analysis | E11 | Added beige cell for data entry | N/A |
| IV Addl - Analysis | F10 | Added instructions for data entry for additional data element | Use the beige cell below to indicate the time period of the other health care payer rates in column F. |
| IV Addl - Analysis | F11 | Added beige cell for data entry | N/A |
| IV Addl - Analysis | B12 | Removed capitalization | Benefit Ccategory |
| IV Addl - Analysis | C12 | Replaced text | Sum of the Medicaid payment rates in the aggregate BEFORE rate reduction or restructuring |
| IV Addl - Analysis | D12 | Replaced text | Sum of the Medicaid payment rates in the aggregate AFTER rate reduction or restructuring |
| IV Addl - Analysis | E12 | Replaced text | Number of Individual Ratios |
| IV Addl - Analysis | F12 | Replaced text | Sum of the ratios of Medicaid payment rates to the comparable Medicare rate BEFORE rate reduction or restructuring |
| IV Addl - Analysis | G12 | Replaced text | Sum of the ratios of Medicaid payment rates to the comparable other health care payer rate BEFORE rate reduction or restructuring |
| IV Addl - Analysis | H12 | Replaced text | Sum of the ratios of Medicaid payment rates to the comparable Medicare rate AFTER rate reduction or restructuring |
| IV Addl - Analysis | I12 | Replaced text | Sum of the ratios of Medicaid payment rates to the comparable other health care payer rate AFTER rate reduction or restructuring |
| IV Addl - Analysis | J12 | Replaced text | Average taken of the ratios of Medicaid rates (BEFORE rate reduction or restructuring) to Medicare |
| IV Addl - Analysis | K12 | Replaced text | Average taken of the ratios of Medicaid rates (BEFORE rate reduction or restructuring) to health care payer |
| IV Addl - Analysis | L12 | Replaced text | Average taken of the ratios of Medicaid rates (AFTER rate reduction or restructuring) to Medicare |
| IV Addl - Analysis | M12 | Replaced text | Average taken of the ratios of Medicaid rates (AFTER rate reduction or restructuring) to health care payer |
| IV Addl - Analysis | C13 | Replaced text | 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 +$200). |
| IV Addl - Analysis | D13 | Replaced text | Enter the dollar ($) 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). |
| IV Addl - Analysis | E13 | Replaced text | 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. |
| IV Addl - Analysis | F13 | Replaced text | 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%). |
| IV Addl - Analysis | G13 | Replaced text | 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%). |
| IV Addl - Analysis | H13 | Replaced text | 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%). |
| IV Addl - Analysis | I13 | Replaced text | 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%). |
| V Addl - Providers | D6 | Removed capitalization | Start date |
| V Addl - Providers | E6 | Removed capitalization | End date |
| V Addl - Providers | A13 | Edits to text | 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. |
| V Addl - Providers | B14 | Removed capitalization | Benefit Ccategory |
| V Addl - Providers | B15 | Edits to text | Auto populated from the benefit category entered on the "IV Addl - Analysis" tab |
| V Addl - Providers | N15 | Edits to text | 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 |
| VI Addl - Beneficiary | A1 | Capitalization | VI. Beneficiaries Receiving Services |
| VI Addl - Beneficiary | A4 | Edits to text | 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. |
| VI Addl - Beneficiary | D6 | Removed capitalization | Start date |
| VI Addl - Beneficiary | E6 | Removed capitalization | End date |
| VI Addl - Beneficiary | A13 | Edits to text | 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). |
| VI Addl - Beneficiary | C15 | Removed capitalization | Data format |
| VI Addl - Beneficiary | A21 | Edits to text | 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 immeidately 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). The state will include beneficiaries who received any services subject to the proposed payment rate reduction or payment restructuring. |
| VI Addl - Beneficiary | B22 | Removed capitalization | Benefit Ccategory |
| VI Addl - Beneficiary | B23 | Edits to text | Auto populated from the benefit category entered on the "IV Addl - Analysis" tab |
| VI Addl - Beneficiary | AL22 | Edits to text | Trend of number of beneficiaries who are living with disabilities receiving services from Year 1 2 to Year 2 3 |
| VI Addl - Beneficiary | AP23 | Edits to text | 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 |
| VI Addl - Beneficiary | Columns P - X | Edits to formulas and formatting | NOTE ON FORMULA AND FORMATTING CHANGES: For Columns P - X, the formulas were changed to round to two decimal places, and the cells were formatted to show the results to two decimal places. |
| VII Addl - Services | A1 | Capitalization | VII. Medicaid Services |
| VII Addl - Services | A4 | Edits to text | 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. |
| VII Addl - Services | D6 | Removed capitalization | Start date |
| VII Addl - Services | E6 | Removed capitalization | End date |
| VII Addl - Services | A13 | Edits to text | 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). |
| VII Addl - Services | C15 | Removed capitalization | Data format |
| VII Addl - Services | A21 | Edits to text | 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). The state will include any services furnished through FFS subject to the proposed payment rate reduction or payment restructuring. |
| VII Addl - Services | B22 | Removed capitalization | Benefit Ccategory |
| VII Addl - Services | B23 | Edits to text | Auto populated from the benefit category entered on the "IV Addl - Analysis" tab |
| VII Addl - Services | X22 | Edits to text | Proportion of Medicaid services furnished to beneficiaries living with disabilities - Year 1 |
| VII Addl - Services | Y22 | Edits to text | Proportion of Medicaid services furnished to beneficiaries living with disabilities - Year 2 |
| VII Addl - Services | Z22 | Edits to text | Proportion of Medicaid services furnished to beneficiaries living with disabilities - Year 3 |
| VII Addl - Services | AC22 | Edits to text | Change in the number of Medicaid services furnished through FFS from Year 1 to Year 3 |
| VII Addl - Services | AR23 | Edits to 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, for each geographic area |
| VII Addl - Services | Columns R - Z | Edits to formulas | NOTE ON FORMULA AND FORMATTING CHANGES: For Columns R - Z, the formulas were changed to round to two decimal places, and the cells were formatted to show the results to two decimal places. |
| VIII Addl - Concerns | A1 | Capitalization | VIII. Summary of Access to Care Concerns or Complaints |
| VIII Addl - Concerns | A4 | Edits to text | 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)(i) 447.203(c)(2)(vi). The state must also include its response to these concerns. |
| VIII Addl - Concerns | C6 | Removed capitalization | Data format |
| Instructions | D51 | Redlined instructions and definition column with updated langauge. | 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 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). |
| This tab describes the differences between the template posted for public comment on November 19, 2025 and the template submitted with the PRA package on January 21, 2026. | ||||
| Worksheet | Cell Reference in "2025_09_17_Template_Clean_Unlocked_for initial 508.xlsx" | Description of Change | Changes to Text in Blue | FMG Comments |
| State attestation | B2 | Created a warning if B5/B6 not both filled in. (yellow background/red font) | n/a | |
| Progress Tracker | New Worksheet | Created new worksheet called "Progress Tracker". This is a auto-generated tab and will be locked. Updates progress with completed cells, required cells, and % to complete. | n/a | |
| 0 Summary of compliance | E1 | Created a warning if D6:D11 not filled in. (yellow background/red font) | n/a | |
| 0 Summary of compliance | F1 | Created a warning if B28 not filled in when D16:D18 = "Met". (yellow background/red font) | n/a | |
| 0 Summary of compliance | C23 | Added a notification as to whether a state should complete B23 based on responses in D16:D18. | n/a | |
| I 80% Medicare | D4 | Created a warning if any of the column I results are incomplete. (yellow background/red font) | n/a | |
| I 80% Medicare | I6:K207 | Three new helper columns called Progress Indicator, Incomplete Cell Counts, and Required Cell Counts created. Will be hidden in final format. Incomplete = if there is a missing data cell in cols B8:F207. If no data is entered in a row, column I shows blank. | n/a | |
| I 80% Medicare | C4 | Created a warning if A5 not filled in. (yellow background/red font) | n/a | |
| I 80% Medicare | B8:F207 | Added conditional formatting to highlight the row in yellow if there is a missing data entry in a row. If a row is completely blank, leave it as-is (in beige color). | n/a | |
| II 4% Aggregate | C4 | Created a warning if A5 not filled in. (yellow background/red font) | n/a | |
| II 4% Aggregate | D4 | Created a warning if any of the column I results are incomplete. (yellow background/red font) | n/a | |
| II 4% Aggregate | I6:K207 | Three new helper columns called Progress Indicator, Incomplete Cell Counts, and Required Cell Counts created. Will be hidden in final format. Incomplete = if there is a missing data cell in cols B6:F207. This will only activate if there is data available (i.e., not "--") in columns B6:D207. If no data is entered in a row, column I shows blank. | n/a | |
| II 4% Aggregate | E7:F207 | Added conditional formatting to highlight the row in yellow if there is a missing data entry in a row. This will only activate if there is data available (i.e., not "--") in columns B8:F207. If a row is completely blank, leave it as-is (in beige color). | n/a | |
| III Public Process Attestation | B2 | Created a warning if B3:B4 not both filled in. (yellow background/red font) | n/a | |
| IV Addl - Analysis - UPDATED | New Worksheet | Inserted new worksheet with redlined edits from previous worksheet. | n/a | |
| IV Addl - Analysis - UPDATED | C1 | If 0 Summary of Compliance D16:D18 = "Met", then worksheets IV - VIII are not required. Shows "Per tab 0 Summary of compliance, Table B, do not complete this spreadsheet." message. (yellow background / red font) | n/a | |
| IV Addl - Analysis - UPDATED | E1 | Created a warning if E5, A9, B9 not filled in. (yellow background/red font) | n/a | |
| IV Addl - Analysis - UPDATED | F1 | Created a warning if any of the column N12:N211 results are incomplete. (yellow background/red font) | n/a | |
| IV Addl - Analysis - UPDATED | N10:P211 | Three new helper columns called Progress Indicator, Incomplete Cell Counts, and Required Cell Counts created. Will be hidden in final format. Incomplete = if there is a missing data cell in cols B12:I211. If no data is entered in a row, column I shows blank. | n/a | |
| IV Addl - Analysis - UPDATED | B12:I211 | Added conditional formatting to highlight the row in yellow if there is a missing data entry in a row. If a row is completely blank, leave it as-is (in beige color). | n/a | |
| V Addl - Providers | D1 | If 0 Summary of Compliance D16:D18 = "Met", then worksheets IV - VIII are not required. Shows "Per tab 0 Summary of compliance, Table B, do not complete this spreadsheet." message. (yellow background / red font) | n/a | |
| V Addl - Providers | E1 | Created a warning if D5:E7 not filled in. (yellow background/red font) | n/a | |
| V Addl - Providers | F1 | Created a warning if any of the column O12:O211 results are incomplete. (yellow background/red font) | n/a | |
| V Addl - Providers | O12:Q211 | Three new helper columns called Progress Indicator, Incomplete Cell Counts, and Required Cell Counts created. Will be hidden in final format. Incomplete = if there is a missing data cell in cols C12:H211 and M12:N211. This will only activate if there is data available (i.e., not "--") in columns B12:B211. If no data is entered in a row, column O12:O211 shows blank. | n/a | |
| V Addl - Providers | C12:H211, M12:N211 | Added conditional formatting to highlight the row in yellow if there is a missing data entry in a row. This will only activate if there is data available (i.e., not "--") in columns B12:B211. If a row is completely blank, leave it as-is (in beige color). | n/a | |
| VI Addl - Beneficiary | D1 | If 0 Summary of Compliance D16:D18 = "Met", then worksheets IV - VIII are not required. Shows "Per tab 0 Summary of compliance, Table B, do not complete this spreadsheet." message. (yellow background / red font) | n/a | |
| VI Addl - Beneficiary | E2 | Created a warning if D5:E7 and D11:D12 not filled in. (yellow background/red font) | n/a | |
| VI Addl - Beneficiary | F2 | Created a warning if any of the column AQ18:AQ217 results are incomplete. (yellow background/red font) | n/a | |
| VI Addl - Beneficiary | AQ18:AS217 | Three new helper columns called Progress Indicator, Incomplete Cell Counts, and Required Cell Counts created. Will be hidden in final format. Incomplete = if there is a missing data cell in cols B18:B217. This will only activate if there is data available (i.e., not "--") in columns B18:B217. If no data is entered in a row, column I shows blank. | n/a | |
| VI Addl - Beneficiary | B18:O217, AO18:AP217 | Added conditional formatting to highlight the row in yellow if there is a missing data entry in a row. This will only activate if there is data available (i.e., not "--") in columns B18:B217. If a row is completely blank, leave it as-is (in beige color). | n/a | |
| VII Addl - Services | C1 | If 0 Summary of Compliance D16:D18 = "Met", then worksheets IV - VIII are not required. Shows "Per tab 0 Summary of compliance, Table B, do not complete this spreadsheet." message. (yellow background / red font) | n/a | |
| VII Addl - Services | E2 | Created a warning if D5:E7 and D11:D12 not filled in. (yellow background/red font) | n/a | |
| VII Addl - Services | F2 | Created a warning if any of the column AS18:AS217 results are incomplete. (yellow background/red font) | n/a | |
| VII Addl - Services | AS18:AU217 | Three new helper columns called Progress Indicator, Incomplete Cell Counts, and Required Cell Counts created. Will be hidden in final format. Incomplete = if there is a missing data cell in cols F18:Q217 & AQ18:AR217. This will only activate if there is data available (i.e., not "--") in columns B18:E217. If no data is entered in a row, column I shows blank. | n/a | |
| VII Addl - Services | B18:Q217, AQ18:AR217 | Added conditional formatting to highlight the row in yellow if there is a missing data entry in a row. This will only activate if there is data available (i.e., not "--") in columns B18:E217. If a row is completely blank (and B18:E217 is "--"), leave it as-is (in beige color). | n/a | |
| VIII Addl - Concerns | D3 | Created a warning if D5:D6 not filled in. (yellow background/red font) | n/a |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |