On June 26, the Centers for Medicare & Medicaid Services (CMS) released the Notice of Funding Opportunity (NOFO) for the Transforming Maternal Health (TMaH) Model. TMaH is ten-year delivery and payment model designed to test whether effective implementation of evidence‑informed interventions, sustained by a value-based payment (VBP) model, can improve maternal outcomes and reduce Medicaid and Children's Health Insurance Program (CHIP) expenditures. CMS will issue cooperative agreements to up to 15 State Medicaid Agencies (SMAs) to participate in the TMaH Model. Each selected SMA will be eligible for up to $17 million over the course of the model (January 20, 2025 to January 19, 2035) with up to $8 million for Pre-Implementation in Model Years 1–3 and up to $9 million for Implementation in Model Years 4–10. Applications to participate in the TMaH Model are due on September 20, 2024 by 11:59 pm ET. The anticipated award date is January 13, 2025.
The TMaH application and the implementation of the model are comprehensive and resource intensive, requiring input from multi-disciplinary teams across SMAs (and possibly other agencies, like Maternal and Child Health), as well as deep engagement with community partners. As states consider whether to apply for TMaH and how to approach implementation, the speed and staff resources required are top of mind. Some states are certainly contemplating whether the up to $17 million award funding is sufficient for implementing all the requirements of the model, particularly considering that states could choose to (and providers will be advocating for) allocation of up to $5 million of the pre-implementation award for provider capacity building. As they consider these questions and prepare their applications, state Medicaid agencies and their TMaH partners, including providers and managed care plans, need to think about the following:
- Alignment with existing maternity priorities. SMAs, providers and managed care plans should consider their existing maternity initiatives and partnerships and what more they want to implement building upon prior work that participation in TMaH may catalyze (e.g., whether available funds and technical assistance could accelerate ongoing initiatives).
- Determining a test region. States will need to determine whether they plan to implement TMaH at a sub-state level or statewide. When making this decision, SMAs will need a keen understanding of statewide and regional differences in health outcomes, availability of resources and interest among key TMaH partners, including providers and managed care plans. Notably, all managed care plans in the proposed test region must participate in TMaH. Understanding both quantitative information (informed by Medicaid data, clinical quality measures, vital statistics and other data points) as well as qualitative (informed by provider surveys, stakeholder engagement, enrollee experience, information shared by communities) can help States provide a clearer picture in their applications of how they intend to proceed. For States proposing a sub-state test, their applications will need to indicate a comparison substate region.
- Approach to VBP. CMMI provided more details about the proposed TMaH provider payment. SMAs, providers and managed care plans should keep several things in mind regarding the payment approach:
- Whether and to what degree the measures selected for the Performance Incentive Payment align with existing health indicators and measures.
- Additional state budgetary needs for funding the Performance Incentive Payments, since CMS indicates the cooperative agreement funds cannot be used to fund the Performance Incentive Payment.
- Existing provider network and capacity in the proposed test region to work with SMAs and managed care plans to adopt TMaH measures and transition to the VBP model.
- The role of managed care plans in building capabilities and partnering with providers to transition to the VBP model.
- It is unclear how much flexibility SMAs will have in tailoring the VBP model to best meet the needs of their Medicaid programs; however, the VBP approach outlined presents an opportunity for States, managed care plans and providers to collaborate and inform the payment model design and implementation.
Next Steps and More Information
TMaH Model and Application Requirements
Determining TMaH Implementation Region and Model Partners
SMAs must propose either to implement the model statewide or in a sub-state region; CMS indicated a strong preference for sub-state implementation for evaluation purposes. For States opting for sub-state implementation, SMAs must propose test and comparison regions that have little to no service overlap. The test region must have evidence of poor birth outcomes or high levels of disparities in outcomes and include more than one managed care plan (if a managed care State). SMAs are encouraged to include rural, underserved and tribal areas in its proposed test regions. The comparison region must be similar to the test region in demographic composition, resource availability and population size and density. For states opting for statewide implementation, SMAs must propose at least three comparable states for patient-level comparison. Regardless of whether a SMA proposes statewide or sub-state implementation, the average number of Medicaid- and CHIP-covered births in the test region between CY2015-2020 must be no less than 1,000 per year.
SMAs are expected to collaborate with providers, including OB/GYNs, midwives, maternal fetal medicine specialists, doulas, lactation consultants and perinatal community health workers; care delivery locations, including hospitals, OB/GYN practices, Federally Qualified Health Centers (FQHCs), tribal sites and birth centers; and partner organizations, including managed care plans, state public health departments, maternal mortality review committees and community-based organizations to implement the Model. SMAs must specify whether provider participation will be voluntary or mandatory in the test region.
Understanding the TMaH Care Delivery Model and Evaluation Focus
The TMaH Model is organized into three pillars: Access, Infrastructure and Workforce; Quality Improvement and Patient Safety; and Whole-Person Care Delivery. There are ten required elements that States must reflect in their applications across the three pillars, as well as eight optional model elements; model elements are informed by evidence they improve maternal health outcomes. Optional elements must be identified in the application and cannot be added after the award; selection of optional elements will not be scored during application review.
The TMaH model includes a three-year Pre-Implementation Period and a seven-year Implementation Period. During the Pre-Implementation Period, SMAs will receive technical assistance to help achieve Pre-Implementation milestones across the model’s required and optional elements. Technical assistance topics will include, but not be limited to, Medicaid data linkage and data sharing and Medicaid claims data analytics and financial modeling; a project officer and TA coach will be assigned to each SMA to help achieve project milestones and support model implementation.
To measure the TMaH model's impact, CMS specified that it will evaluate rates of low-risk cesarean section (c-section); severe maternal morbidity (SMM); incidence of low birthweight infants; changes in experience of care for those who are pregnant, giving birth or postpartum; and changes in Medicaid and CHIP program maternity and infant expenditures.
Tracking the TMaH Payment Parameters
Cooperative Agreement Funding for SMAs
Funding under TMaH can only be used for supportive functions necessary to implement the model (e.g., SMA infrastructure needs, including to hire and retain staff, perform data analytics and build skills and capacity to implement the payment model). Funding cannot be used to duplicate or supplant other funding sources, including state Medicaid and CHIP coverage.
VBP Model Payment to Providers
Implementation of a VBP model is a required model element and will occur in three phases: 1) payments to providers to support care delivery and infrastructure changes, 2) upside-only performance incentive payments to providers and 3) transition from current maternal care payment methodologies to a VBP approach.
Beginning no later than the first quarter of Model Year 3, SMAs must use a portion of their cooperative agreement funding to pay providers and care delivery locations for care delivery transformation activities. The Provider Infrastructure Payments will be based on the number of attributed TMaH Model-eligible Medicaid beneficiaries and will be risk adjusted. CMS will work with each SMA to conduct data analyses to determine the risk-adjusted payment amount. The Provider Infrastructure Payments can support care delivery and infrastructure changes permitted by CMS, such as risk assessments, quality measure reporting, data integration and/or coordinating with CBOs to address HRSNs and behavioral health needs.
In Model Year 4, providers and care delivery locations will become eligible for Quality- and Cost-Performance Incentive Payments. Providers may earn a percentage of their total Medicaid payments for pregnancy-related services for TMaH Model-attributed beneficiaries. The percentage of the Performance Incentive Payment will be proposed by each SMA, subject to CMS approval. Providers will receive Performance Incentive Payments retrospectively based on their Model Year 4 performance on low-risk C-sections, maternal depression screening and follow-up, severe obstetric complications and timeliness of prenatal and postpartum care. Using two to three years of historical claims data and vital records, CMS will establish risk-adjusted quality and cost benchmarks for calculating the upside-only performance payment amount. The payment amount will be based on a provider’s aggregate score for quality performance, worth 80 percent of the total PIP, and cost performance, worth 20 percent of the total Performance Incentive Payment. Cooperative agreement funding cannot be used for Performance Incentive Payments.
By the end of Model Year 5, SMAs must transition from their current payment approaches (e.g., Fee-for-Service (FFS) and, where applicable, OB global payments and facility fees), and the preceding TMaH Model payment structures (Provider Infrastructure Payments and Performance Incentive Payments) to implementing a VBP model. While CMS will lead the design of the VBP model, SMAs selected for TMaH and other key stakeholders will have the opportunity to provide input into the VBP model.