TMaH_NOFO_Final_6.26.24.pdf

U.S. Department of Health and Human Services

Centers for Medicare & Medicaid Services

Center for Medicare and Medicaid Innovation

Transforming Maternal Health (TMaH) Model

Notice of Funding Opportunity Type: New

Funding Opportunity Award Type: Cooperative Agreement

Notice of Funding Opportunity Number: CMS-2N2-25-001

Federal Assistance Listings Number (CFDA): 93.869

Notice of Funding Opportunity Posting Date: June 26, 2024

Applicable Dates:

Letter of Intent to Apply Due Date: August 8, 2024, 11:59 pm Eastern Standard

Time

Electronic Application Due Date: September 20, 2024, 11:59 pm Eastern Standard

Time

Anticipated Issuance Notice(s) of Award: January 13, 2025

Anticipated Period of Performance: January 20, 2025 through January 19, 2035

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TABLE OF CONTENTS

Executive Summary

A. Program Description

A.1 Purpose

A.2 Authority

A.3 Background

A.4 Program Requirements A.4.1 Model Pillars and Elements A.4.2 Care Delivery Model and Milestones A.4.3 Medicaid Payment Model A.4.4 Measure Reporting A.4.5 Availability of Technical Assistance to Recipients A.4.6 Measures and Reporting A.4.7 Medicaid and CHIP Authorities A.4.8 Cooperation with Evaluation

A.5 Technical Assistance and Information for Prospective Applicants

B. Federal Award Information

B.1 Total Funding

B.2 Cooperative Agreement Funding Per Recipient

C. Eligibility Information

C.1 Eligible Applicants

C.2 Cost Sharing or Matching

C.3 Letter of Intent

C.4 Ineligibility Criteria

C.5 Single Application Requirement

C.6 Continued Eligibility

C.7 EIN, UEI, and SAM Regulations

C.8 Faith-Based Organizations

C.9 Other Eligibility Requirements

D. Application and Submission Information

D.1 Address to Request Application Package

D.2 Content and Form of Application Submission D.2.1 Standard forms D.2.2 Application cover letter or cover page (Optional)

D.3 Program Requirements and Expectations D.3.1 Project Narrative

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D.3.2 Budget Narrative (maximum 10 pages) D.3.3 Appendices D.3.4 Business assessment of applicant organization (maximum 12 pages) D.3.5 Program Duplication Assessment (maximum 10 pages)

D.4 Unique Entity Identifier and System for Award Management (SAM)

D.5 Submission Dates and Times

D.6 Intergovernmental Review

D.7 Cost Restrictions

D.8 Mandatory Disclosure

D.9 HHS Form 690

E. Application Review Information

E.1 Criteria

E.2 Merit Review and Selection Process

E.3 Federal Awardee Performance Integrity Information System (FAPIIS)

F. Federal Award Administration Information

F.1 Federal Award Notices

F.2 Administrative and National Policy Requirements

F.3 Terms and Conditions

F.4 Cooperative Agreement Terms and Conditions of Award

F.5 Health Information Technology (IT) Interoperability Language

F.6 Reporting F.6.1 Monitoring

G. CMS Contacts

G.1 Programmatic Questions

G.2 Administrative/Budget Questions

H. Other Information

Appendix I. Guidance for Preparing a Budget Request and Narrative

Appendix II. Application and Submission Information

Appendix III. Business Assessment of Applicant Organization

Appendix IV. Accessibility Requirements

Appendix V. Merit Review and Selection Process

Appendix VI. Application Check-off List

Appendix VII. Glossary

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EXECUTIVE SUMMARY

The Centers for Medicare & Medicaid Services (CMS), through its Center for Medicare and

Medicaid Innovation, is soliciting applications for the Transforming Maternal Health (TMaH)

Model. This is a voluntary, 10-year service delivery and payment model designed to improve maternal health care outcomes for people enrolled in Medicaid and the Children's Health

Insurance Program (CHIP).

The TMaH Model will test whether targeted technical (TA) assistance, coupled with payment and delivery system reforms, can drive a whole-person care-delivery approach to pregnancy, childbirth, and postpartum care while reducing Medicaid and CHIP program expenditures.

CMS will select up to 15 state Medicaid agencies (SMAs or Recipients) to participate in the

TMaH Model. Up to $17 million dollars in Cooperative Agreement Awards will be available to each selected Recipient over the course of the 10-year period of performance for a total of up to

$225M investment.

CMS will evaluate the following: the TMaH Model’s impact on 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 expenditures. The TMaH Model aims to improve maternal and child health outcomes while reducing Medicaid and CHIP program expenditures for maternal care through reduced spending on high-cost procedures such as c-sections for low-risk beneficiaries.

TABLE 1 EXECUTIVE SUMMARY

Item Description

HHS Awarding Agency Centers for Medicare & Medicaid Services (CMS)

CMS Awarding Center Center for Medicare and Medicaid Innovation

Notice of Funding Opportunity Title Transforming Maternal Health (TMaH) Model

Authorization Section 1115A of the Social Security Act (the Act), as added by Section 3021 of the Patient Protection and

Affordable Care Act

Federal Assistance Listings Number

(CFDA)

93.869

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Funding Opportunity Type New

Funding Opportunity Number CMS-2N2-25-001

Type of Award Cooperative Agreement

Type of Competition Competitive

Letter of Intent CMS recommends a letter of intent to apply for this funding opportunity. These are optional. See Section C.3

Letter of Intent for more information.

Application Due Date and Time September 20, 2024, by 11:59 pm EST (Baltimore, MD)

Anticipated Issuance Notice(s) of

Award

January 13, 2025

Period of Performance Start Date January 20, 2025

Period of Performance End Date January 19, 2035

Anticipated Total Available Funding $255 million (Subject to availability of funds)

Estimated Maximum Award Amount $17 million per Recipient

Estimated Maximum Number of

Awards

A. PROGRAM DESCRIPTION

A.1 PURPOSE

This Notice of Funding Opportunity (NOFO) provides details and instructions on how to apply to the Transforming Maternal Health (TMaH) Model.

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Poor maternal outcomes result from many factors that may be addressed with different interventions. The TMaH Model will test whether effective implementation of a package of evidence-informed interventions, sustained by a value-based payment model, can improve maternal outcomes, and reduce Medicaid and CHIP program expenditures.

The goals for the TMaH Model include the following:

• Reduced rates of low-risk c-sections.

• Reduced incidence of severe maternal morbidity.

• Reduced rates of low-birthweight infants.

• Improved experience of perinatal care.

• Reduced Medicaid and CHIP program expenditures for maternity and infant care.

TMaH Model consists of two distinct phases:

• a three-year Pre-Implementation Period

• a seven-year Implementation Period.

Pre-Implementation Period funding and technical assistance will help the Recipient build critical skills and capacity to successfully launch a value-based payment model that supports delivery of whole-person care during the seven-year Implementation Period. Participation in the TMaH

Model will require significant effort, collaboration and staff time from the Recipient to set the foundation for success, given the historic underinvestment in maternal health care.

Recipients will be expected to define one or more geographic areas in which to implement the

TMaH Model. Recipients are expected to include their CHIP population if pregnant individualsi receive services through CHIP in their state. Recipients in states that have implemented managed care in their Medicaid and/or CHIP programs are required to collaborate with at least one risk-based managed care plan (MCP)ii to implement the model.

Recipients will work with:

• Partner Providers (e.g. obstetricians, midwives and other clinical and support staff such as doulas; see Appendix VII Glossary for additional details)

• Partner Care Delivery Locations (e.g. hospitals, birth centers, FQHCs and other sites of care; see Appendix VII Glossary for additional details) and

• Partner Organizations (e.g. MCPs, state public health departments, community-based organizations and other non-clinical partners; see Appendix VII Glossary for additional details) to implement the model.

All Recipients must adhere to the TMaH payment model timeline set forth in this paragraph and detailed further in Section A.4.3.

• In the first two years of the Pre-Implementation Period (Model Years 1-2), Recipients will work with CMS to develop and implement a detailed technical assistance and tailored work plan with defined tasks, timelines and benchmarks that will support achievement of model elements.

i Throughout this document, we use the term “pregnant women” when aligning with cited literature.

ii In this document, the term “managed care plan” refers to managed care organizations, prepaid inpatient health plans and prepaid ambulatory health plans with a risk-contract with the State as defined in 42 CFR § 438.2.

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• Beginning no later than the final year of the Pre-Implementation Period (Model Year 3), Recipient will use a portion of their Cooperative Agreement Awards to provide financial assistance to providers for care delivery transformation activities; these payments are called Provider Infrastructure Payments.

• In Model Year 4, providers may receive, from State funds (and not using the Cooperative

Agreement Awards), retrospective performance payments on a set of quality and cost measures.

• In Model Year 5, Recipients will transition to a new value-based payment model to be finalized during the Pre-Implementation Period. The design of the value-based payment model will be led by CMS in partnership with the Recipients and other stakeholders;

these design discussions will begin in Model Year 1.

The requirements and expectations for the TMaH Model are detailed throughout this NOFO.

Specific information regarding TMaH Model requirements are detailed in Section A.4

Program Requirements. For key terms and definitions used throughout this NOFO, see

Appendix VII. Glossary.

A.2 AUTHORITY

Section 1115A of the Social Security Act (the Act), as added by Section 3021 of the Affordable

Care Act, authorizes the Secretary of the Department of Health and Human Services to test innovative payment and service delivery models to reduce Medicare, Medicaid, and CHIP expenditures while preserving or enhancing the quality of care.

A.3 BACKGROUND

Despite spending more per capita for maternity care than any other nation, the U.S. has higher rates of adverse pregnancy outcomes than any other high-income country.1 In 2022, the U.S.

maternal mortality rate was 22.3 deaths per 100,000 live births. The Centers for Disease Control and Prevention (CDC) reports that more than 80 percent of pregnancy-related deaths are preventable.2 Mortality is a relatively rare event, but the rate of severe maternal morbidity is also unacceptably high (rate = 88.2/10,000 delivery hospitalizations in 2020, the latest year for which national data are available).3 Moreover, with 53 percent of pregnancy-related deaths occurring 7 days to a year after delivery, there is an urgent need to address the chronic conditions and mental health needs that are driving maternal morbidity and mortality in the postpartum period.4

Maternal morbidities may be treatable and controlled if detected early, preventing catastrophic outcomes. For example, treatment of mild chronic hypertension before the twenty-third week of pregnancy is associated with reduced risk of preeclampsia, a pregnancy-related hypertensive disorder.5 Extension of Medicaid and CHIP eligibility to 12 months postpartum in a majority of states creates opportunities to effectively address these postpartum risks.6,7

In 2022, Medicaid financed 41.3 percent of all U.S. births.8 In 2021, Medicaid financed 64 percent of births to non-Hispanic Black mothers and 58.1 percent of those to Hispanic mothers.9

In 2018, Medicaid financed about half of births in rural areas.10 Medicaid beneficiaries have a greater risk of significant disparities in cost, quality, care, and outcomes compared with those who are commercially insured.11In 2021, non-Hispanic Black women had SMM rates nearly twice as high as those among non-Hispanic White women (156.8 per 10,000 deliveries vs. 83.4

2024-06-26 Page 6 of 111 per 10,000 deliveries).12 Moreover, preventive care to detect, treat and manage chronic conditions such as hypertension and diabetes, as well as mental health conditions and substance use disorders, is essential to mitigate pregnancy-related complications, but research shows that

Black persons are less likely to receive preventive health care, in part due to poorer access to prenatal and postpartum care.13

Factors Contributing to Current Outcomes

Below, we describe key issue areas that affect maternal health outcomes, including the following: 1) access, infrastructure, and workforce; 2) quality improvement and patient safety;

and 3) whole-person care. Section A.4 Program Requirements will detail how Recipients must use this funding opportunity to address these issues.

Access, Infrastructure and Workforce

Adequate coverage and provider capacity are critical to access to care along the prenatal, pregnancy, and postpartum continuum. As the 2022 HRSA State of the Maternal Health

Workforce Brief highlighted, several clinical specialties provide pregnancy-related care.14

Nonetheless, with a ratio of just 11 obstetricians (OBs) and four midwives for every 1,000 live births,15 pregnant women who attempt to access high-quality maternity care may face serious challenges. The integration of midwives and doulas into the perinatal workforce is an important 16, 17, 18, 19, 20 21, 22,strategy to build the workforce while improving access to risk-appropriate care.

23, 24

Social context and poverty also play a big part in maternal health and outcome disparities.

Pregnant women with low socioeconomic status have higher rates of maternal mortality,25 and those living in areas with limited access to nutritious food have higher odds of at least one comorbid condition in pregnancy such as preeclampsia, gestational hypertension, gestational diabetes, and preterm labor than people who do not live in food deserts.26 Studies consistently find that predominantly Black neighborhoods have fewer supermarkets compared with predominantly White neighborhoods and that a lower proportion of stores in Black neighborhoods carry fresh produce.27 Rural communities are at increased risk of food insecurity.28 After controlling for sociodemographic and clinical factors, rural women have a 9 percent higher probability of SMM, compared with their urban counterparts.29,30 Enrollment in

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has been shown to significantly reduce preterm birth and infant mortality among Medicaid beneficiaries,31 but only about half of WIC-eligible people are enrolled in the program.32 Many state Medicaid agencies do not regularly participate in data matching with other benefits programs such as WIC that would increase cross-enrollment and decrease administrative burden on beneficiaries.

In addition, valuable data about patient conditions and treatment remain locked in paper charts or electronic health records that are not shared between providers, with community-based organizations (CBOs) or across agencies that could address health and health-related social needs

(HRSNs). For example, the comprehensive individual and population-level health picture that could emerge from linkage of parents and infants in Medicaid, vital records, and hospital discharge data remains incomplete in most states. Furthermore, hospital discharge data in state and regional Health Information Exchanges (HIE) may not share the same information at the same level of detail or in the same format. For example, continuity of care information may be

2024-06-26 Page 7 of 111 entered into online forms or stored as portable document files (pdf). Lack of interoperability and linkage among state administrative data and federal programs such as WIC may be a barrier to enrollment for eligible people. State and federal privacy laws may further limit data sharing absent explicit written permission to do so.

Recipients and MCPs use a variety of approaches to manage cost and utilization of maternal health services. Obstetrics and midwifery providers are paid a professional fee for their services and often receive global reimbursement for a package of services, which may be unconnected to performance or outcomes.33 In addition, a facility fee is paid separately to the delivery site.

Hospital facility payments for cesarean sections are often higher than for vaginal births due to the use of operating rooms and hospital-based labor and supplies. However, it is important to note this fee is not paid to the delivering provider.34 One study found that the average Medicaid

Fee-for-Service (FFS) hospital facility payment for cesarean delivery can be more than 40 percent higher than for vaginal delivery.35 Neither FFS payments nor the use of global payments adequately incentivizes team-based care or coordination across the pregnancy episode.36

Quality Improvement and Patient Safety

Not all evidence-informed safety practices are used consistently across birthing facilities.37,38,39

This contributes to poor maternal health outcomes. The Alliance for Innovation on Maternal

Health (AIM) is a quality improvement initiative supported by the Health Resources & Services

Administration. AIM has developed evidence-informed protocols called “patient safety bundles.”

Currently, there are eight core AIM patient safety bundles designed to be implemented at the hospital-level: Obstetric Hemorrhage, Severe Hypertension in Pregnancy, Safe Reduction of

Primary Cesarean Birth, Cardiac Conditions in Obstetric Care, Care for Pregnant and Postpartum

People with Substance Use Disorder, Perinatal Mental Health Conditions, Postpartum Discharge

Transition, and Sepsis in Obstetrical Care. These patient safety bundles are often implemented with the assistance of Perinatal Quality Collaboratives (PQCs)iii. For more information visit the

AIM website.

CMS created a “Birthing-Friendly” hospital designation to recognize high-quality care at hospitals eligible for the Hospital Inpatient Quality Reporting (IQR) Program.40 The “Birthing-

Friendly” hospital designation and the AIM initiative are complementary. To earn the “Birthing-

Friendly” hospital designation, eligible facilities must (1) participate in a statewide or national perinatal quality improvement collaborative program and (2) implement evidence-based quality interventions in hospital settings to improve maternal health. Implementing AIM safety bundles through participation in a state PQC would satisfy the current requirements for the Birthing-

Friendly hospital designation. As the Birthing-Friendly hospital designation requirements evolve through the Hospital IQR Program and/or other CMS quality programs, Recipients would be expected to encourage and support hospitals that are Partner Care Delivery Locations to maintain the designation.

Whole-Person Care Delivery iii The Centers for Disease Control and Prevention defines PQCs as "state or multistate networks of teams working to improve the quality of care for mothers and babies. PQC members identify health care processes that need to be improved and use the best available methods to make changes as quickly as possible."

2024-06-26 Page 8 of 111 https://saferbirth.org/ https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pqc.htm

Currently, most pregnant people receive the same “one size fits all” approach to care that is designed to respond to medical complications, rather than to optimize overall health and wellness for the patient.41 Proper risk-stratification of pregnant people to determine what prenatal care models best meet their physical and behavioral needs and health-related social needs (HRSNs) helps to avoid overmedicalization of maternity care that can lead to complications and worse outcomes.42 Consistent, comprehensive screening is central to risk assessment. Screening for

HRSNs has been less consistently or comprehensively incorporated into routine risk assessment.

Insufficient resources and a lack of protocols often do not support effective referral and follow- 43,44,45 up, further compounding the problem.

Many pregnant women, including Black, Indigenous, People of Color and those with disabilities report a negative perinatal care experience, including feeling that their concerns are unheard or dismissed by overstretched providers who do not have adequate time or culturally competent training.46,47,48,49 Approximately one in five pregnant women overall, and approximately 30 percent of those who are Black, Hispanic, and multiracial, reported mistreatment (e.g., violations of physical privacy or verbal abuse) during maternity care. Approximately 40 percent of Black, Hispanic, and multiracial pregnant women reported discrimination during maternity care, and 45 percent of all pregnant women reported holding back from asking questions or discussing concerns with their provider.50

FIGURE 1 STRUCTURAL OVERVIEW

Previous efforts to improve care and outcomes have usually reinforced the medical model of maternity care. In the United States, the medical model tends to focus on testing, monitoring, and procedure-based management of problems and complications. Common criticisms of the medical model, especially for patients experiencing socioeconomic challenges, include: disrespectful treatment;51,52,53 racial, ethnic, and cultural discordance between providers and patients;54 poor

2024-06-26 Page 9 of 111 continuity of care between providers;55,56 insufficient time for patient education and questions;57 historical medical mistreatment and current distrust, particularly for Black and American Indian and Alaska Native (AI/AN) populations;58 insufficient attention to behavioral health and social drivers of health;59,60 siloed care that impedes information-sharing and team-based care;61 and overuse of certain medical interventions.62

During a three-year Pre- implementation Period, Recipients, managed-care entities and Partner

Providers and Partner Care Delivery Locations will receive intensive TA and funding designed to build critical skills and capacity to successfully implement the TMaH Model elements. CMS and its contractors will support the Recipients in using Medicaid and CHIP authorities to establish coverage for Medicaid and CHIP benefits that are required under the TMaH Model, such as coverage and sustainable payment for Doula Services. CMS will offer TA regarding how to reimburse and support these benefits at sufficient scale to successfully implement the TMaH

Model’s team-based approach. During the seven-year Implementation Period, Recipients will implement value-based payment approaches that support the model of care.

A.4 PROGRAM REQUIREMENTS

A.4.1 MODEL PILLARS AND ELEMENTS

The TMaH Model is organized into three pillars designed to address the key issue areas that affect maternal health outcomes:

• Pillar 1: Access, Infrastructure and Workforce

• Pillar 2: Quality Improvement and Patient Safety

• Pillar 3: Whole-Person Care Delivery

The TMaH Model consists of ten required elements and eight optional elements that have been shown to improve maternal health outcomes. These elements are organized by pillar in Table 2 and further described below. Recipients shall implement the ten required elements, subject to their approved Project Narrative (see Section D.3 Program Requirements and Expectations and

Section E Application Review Information). In addition, applicants may propose to implement one or more of the eight optional elements with the help of technical assistance (TA) and

Cooperative Agreement funding provided by CMS, subject to CMS approval. Election of optional elements may not be desired by all applicants and will depend on the current maternal and perinatal health care system in each state as well as each applicant’s individual objectives, among other state-specific factors. There is no cap on the number of optional elements that may be selected by an applicant. However, except for the extension of postpartum eligibility to 12 months, Recipients will not be allowed to add additional elements to the project scope after award without explicit CMS prior approval. No funding above the annual maximums set by

CMS will be awarded based on the applicant’s election of optional elements.

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TABLE 2 MODEL PILLARS AND ELEMENTS

Required Elements Pillar 1

Access, Infrastructure and Workforce

Pillar 2 Quality Improvement and

Safety

Pillar 3 Whole Person Care Delivery

▪ Increase access to the midwifery workforce

▪ Increase access to birth centers

▪ Coveriv Doula Services

▪ Improve data infrastructure

▪ Develop payment model

▪ Support implementation of AIM patient safety bundles

▪ Support “Birthing-

Friendly” hospital designation

▪ Increase risk assessments, screenings, referrals and follow-up for perinatal depression, anxiety, tobacco use, substance use disorder, and HRSN

▪ Increase home monitoring of diabetes and hypertension

▪ Develop Health Equity

Plan Optional Elements

(Other Available Technical Assistance) Pillar 1

Access, Infrastructure and Workforce

Pillar 2 Quality Improvement and

Safety

Pillar 3 Whole Person Care Delivery

▪ Coverv certified midwives (CMs) and certified professional midwives

(CPMs)

▪ Covervi perinatal community health workers (CHWs)

▪ Create regional partnerships in rural areas

▪ Extend Medicaid eligibility to 12 months postpartum

▪ Promote shared decision-making

▪ Expand group perinatal care

▪ Increase use of home visits, mobile clinics and telehealth

▪ Expand oral health care iv Include Doula Services among those eligible for Medicaid payment v Include certified midwives and/or certified professional midwives among those eligible for Medicaid payment vi Include perinatal community health worker services among those eligible for Medicaid payment

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A.4.2 CARE DELIVERY MODEL AND MILESTONES

The TMaH Model will test a new paradigm of maternity care by increasing access to and expanding the maternal health workforce while also increasing the use of comprehensive clinical and social screenings, risk-appropriate care, safety practices and home monitoring.

Table 3 summarizes each element, the supporting technical assistance activities provided by

CMS (see Section A.4.5 Technical Assistance and Information for Prospective Applicants for additional details) and the Pre-Implementation Period milestones Recipients need to complete by the end of Model Year 3. Most of the technical assistance will be provided to the Recipients.

However, depending on the model element, and at the direction of the Recipient, technical assistance may be provided to Partner Providers, Partner Care Delivery Locations and Partner

Organizations to reach Pre-Implementation Period milestones. Recipients are required to ensure that they or their collaborating MCPs and/or Partner Providers and Partner Care Delivery

Locations, as appropriate, reach all Pre-Implementation Period milestones no later than the end of the Pre-Implementation Period (Model Year 3).

CMS will develop state-specific milestones for Model Years 4-10, including the implementation of the payment model and advancing model elements (see Section F.6.1.2 Programmatic

Reporting for additional information). CMS and Recipient will collaborate to conduct a needs assessment and create a detailed technical assistance plan as part of the initial model activities.

TA will assist Recipients in progressing toward the model’s objectives, while helping to ensure that milestones are met in a timely manner.

TABLE 3 ELEMENTS, TA, AND MILESTONES

Element Technical Assistance Activities Pre Implementation Period Milestones to Complete by the End of Model Year 3

State Medicaid Agencies and Model Participants

Pillar 1 –– Access, Infrastructure and Workforce

Increase access to the midwifery workforce

• Guidance for assessing the state’s midwifery workforce capacity, including by type of midwife and options for covering additional types of midwives licensed in the state

• Guidance for payment analyses that compares the reimbursement rate for midwives as a proportion of a benchmark rate for determining fee schedule updates, as appropriatevii

• Completed an assessment of midwifery workforce capacity in the state and options for covering additional types of midwives licensed in the state

• Assessed and created a billing pathway for interprofessional consultations between midwives and other providers, including maternal fetal medicine specialists, as appropriate and needed

• Completed payment analysis that compares the reimbursement rate for midwives as a proportion of a benchmark rate (for fee schedule updates as appropriate), and has a process in place for completing an annual analysis thereafter

• Guidance to create a billing pathway for midwives (and obstetricians) to consult with vii A benchmark rate could include commercial or other plan rates or reimbursement rates for other clinicians or sites of care performing similar services, as appropriate based on each Recipient’s state context.

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-Element Technical Assistance Activities Pre Implementation Period Milestones to Complete by the End of Model Year 3 maternal fetal medicine specialists without a direct patient encounter (e.g., eConsults).

• Guidance to connect with local and state resources, including

CBOs, community colleges, training organizations and others to expand recruitment, training opportunities, and patient communications around the use and availability of midwives

• Guidance to cover childbirth preparation education classes through state plan amendment

(SPA) or waiver and develop a childbirth education class referral process

Increase access to birth centers

• Guidance for payment analyses that compares the reimbursement rate for birth center facility fees as proportion of a benchmark rate for determining fee schedule updates, as appropriate

• Guidance for establishing more sustainable reimbursement rates for birth centers

• Completed a payment analysis that compares the facility fee rate for birth centers as a proportion of a relevant benchmark rate, and has a process in place for completing an annual analysis thereafter

• Created a plan for providing information to beneficiaries on birth centers, if licensed, accredited and operating in the state

• Completed an implementation plan for establishing more sustainable reimbursement rates for birth centers

Cover Doula

Services

• Guidance to cover all Doula

Services through Medicaid authorities, including defining

Doula Services

• Guidance for rate development and payment analyses, as appropriate, that compares the reimbursement rate for Doula

Services as a proportion of a relevant benchmark rate, for determining fee schedule updates, as appropriate

• Guidance to establish a State

Doula Support Council, if no such group currently exists

• Guidance to connect with local and state resources, including

• Completed workplan for initial payment analysis

• Completed a payment analysis that compares the reimbursement rate for Doula Services as a proportion of a relevant benchmark rate, and has a process in place for completing an annual analysis thereafter

• Submitted, or has a timeline and process in place, for submitting and implementing a State

Plan Amendment (SPA)/waiver to cover Doula

Services if not already covered

• Convened a State Doula Support Council, if such council is newly established

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CBOs, community colleges, historically black colleges and universities, doula training organizations and others to expand recruitment, training opportunities, and communications around the use and availability of Doula Services

• Guidance and trainings for nonclinical trained professionals performing Doula Services to help them enroll in Medicaid and learn about reimbursement structures and billing procedures

• Provider awareness and education to create more supportive care environments for

Doula Services to be furnished

• Information to Medicaid beneficiaries about the availability of Doula Services and benefits of doula service care

Improve data infrastructure

• Guidance to develop IT infrastructure and data use agreements to link Medicaid data with vital records, to link parents and their infants in Medicaid claims and other administrative data sets

•Guidance to Partner Providers, Partner Care Delivery Locations, and other stakeholders, as needed, around data privacy, permitted use and disclosures

• Guidance to improve the collection and stratification of demographic data, including race and ethnicity data as aligned with the Office of the National

Coordinator for Health

Information Technology (ONC)

United States Core Data for

Interoperability (USCDI) and

• Established a timeline and plan for linking Medicaid data and vital records, if the data have not yet been linked by the end of the Pre-Implementation Period.

Plans should include the execution of necessary data-sharing and related agreements for linking Medicaid and vital records. Note: Recipient will identify any state laws and regulations that restrict vital records data-sharing and linkage as required in this NOFO, and should propose solutions for obtaining vital records data elements in their application, if needed. See Section

F.6.1.2 Evaluation

• With TA contractor assistance, Recipient has completed data needs assessment and draft work plan with Partner Providers and Partner Care Delivery

Locations to stratify demographic data, and has identified challenges and has a clear timeline and process for resolution

• With TA contractor assistance, Recipient has completed data needs assessment and draft work plan to identify Model beneficiaries who are also utilizing social service and benefit programs such as WIC/SNAP, 2024-06-26 Page 14 of 111

CMS Office of Minority Health recommendations

• Guidance to Partner Providers about how to improve the collection, exchange, and use of other data important for maternal health as aligned with the USCDI and the USCDI+ Maternal Health data set where appropriate and applicable.viii,ix

• Guidance for data-matching across social service and benefit programs such as WIC/SNAP and

Medicaid to measure and address cross-program enrollment gaps and facilitate auto enrollment, as appropriate

• Guidance to Recipients in understanding allowable uses of the 90 percent enhanced match for various activities related to

Medicaid Information

Technology (IT) in both

Medicaid Management

Information Systems (MMIS) and

Medicaid Eligibility and

Enrollment (E&E) Systems, including the use of Commercial

Off-the-Shelf (COTS) software

• Guidance for improving data flow, consistency and use in state

Health Information Exchanges

• Guidance for Partner Providers and Partner Care Delivery

Locations to implement new data processes, including revising workflows and ensuring staff for the purpose of measuring and addressing cross-program enrollment gaps

• Collect and report stratified demographic data, and match beneficiary data across social service and benefit programs such as WIC/SNAP viii USCDI+ is an initiative to identify and harmonize data elements that go beyond the USCDI to address needs in specific domains. The USCDI+ Maternal Health data set is available here.

ix

Recipients and partner providers can also refer to HHS ONC Informational Resources for maternity health care, NAS, and pediatrics that outline relevant standards (such as the USCDI) and certification criteria that are relevant to maternal health use cases.

2024-06-26 Page 15 of 111 https://uscdiplus.healthit.gov/uscdi?id=uscdi_record&table=x_g_sshh_uscdi_domain&sys_id=75df78228745b95098e5edb90cbb3528&view=sp https://www.healthit.gov/topic/health-it-maternal-and-pediatric-care-and-practice-settings training, e.g. related to collected patient reported experience datax

Develop

Payment

Model

• While CMS will lead the design of the payment model approaches for MY3-5, guidance will be provided to engage in discussions with Recipients including which

Medicaid authority to use to implement the payment model approaches

• Analytic guidance to forecast the impact of potential MY4-

MY5 payment model parameters on utilization, cost, and quality outcomes, using historic data

• Guidance to calculate MY4-

MY5 payment model benchmarks and risk adjustment measures, in addition to other specifications

• Guidance to consider how to foster multi-payer alignment

• Guidance to engage with and communicate the payment model implementation plan to providers and other stakeholders

• Guidance to include maternal health policy priorities in the

Medicaid managed care procurement process

• Guidance to Recipients to gain expertise in the use of managed care contracts as a tool for maternal health quality and access improvement using requirement language, QI conditions, benefit standards, and health outcome expectations

With policy and analytic guidance, created a plan, process and timeline for implementing the MY4 and

MY5 payment requirements, including:

• Using the appropriate Medicaid authority to implement the payment model

• Listed personnel necessary to implement the payment model, including description of roles and responsibilities and budget to support efforts

• Stakeholder engagement plan for ongoing conversations with providers and MCP, where applicable

• Quarterly meeting cadence established with CMS staff and contractors

• Draft payment model implementation workplan submitted to CMS

• Final payment model implementation workplan submitted to CMS, including MCP engagement plan, and MCP contracting timeline

• Establish payment model benchmarks in partnership with CMS, including cost and quality thresholds x Recipients and Partner Providers can also refer to HHS ONC Informational Resources for maternity health care, NAS, and pediatrics that outline relevant standards (such as the USCDI) and certification criteria that are relevant to maternal health use cases.

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Pillar 2 –– Quality Improvement and Patient Safety

Support implementati on of AIM patient safety bundles

• CMS will collaborate with CDC and HRSA to help Recipients foster connections with a PQC to facilitate provider progress toward implementation of relevant AIM patient safety bundles

•Where possible, provide guidance on implementing AIM patient safety bundles into standards-based clinical decision supports (CDS) in electronic health records (EHRs) via

Agency for Healthcare Research and Quality’s CDS Connect tools

• Established partnership (regularly participate in meetings, share information and action items) with PQC or entity leading AIM patient safety bundles to support selection and rollout of AIM patient safety bundles across state, particularly in facilities where no bundles have been implemented

• Designed implementation plan to build capacity for participating in AIM patient safety bundles

• Developed data collection and monitoring plan to support state safety bundle activity

• Work with AIM and PQC convenors to expand database to systematically collect relevant quality, process or structure and outcomes measures data

Support

“Birthing-

Friendly” hospital designation

• Guidance to help Recipients understand “Birthing-Friendly” hospital designation requirements and to help hospitals and Critical

Access Hospitals, which are not required to report data to the

Inpatient Quality Reporting program, overcome challenges to achieving this designation

• Guidance to display the

“Birthing-Friendly” hospital designation in provider directories, where applicable

• Completed analysis of hospitals and Critical Access

Hospitals with birthing facilities to identify challenges in attaining the “Birthing-Friendly” designation and actions that can be taken so that any remaining hospitals achieve the birthing-friendly designation

• Attest that the “Birthing-Friendly” hospital designation is displayed in provider directories, where applicable

Pillar 3 – Whole-Person Care Delivery

Increase risk Risk Assessment Risk Assessment assessments screenings, referrals and follow-up for perinatal depression, anxiety, tobacco use, substance use disorder, and

HRSNs

• Review of current risk assessment tools in use. Plan to implement medical and social risk assessments for risk appropriate care and/or plan to collect information on risk assessments already in use at the practice level

• Guidance to evaluate prenatal to postpartum care delivery patterns and utilization to guide risk assessment design

• Guidance on developing, defining, and implementing

• Identification and selection of risk assessment tools, as appropriate

• Plan to implement medical and social risk assessments for risk appropriate care

Screening/Referral for Behavioral Health Needs

• Drafted a process/journey map of existing screening and referral processes for perinatal beneficiaries with behavioral health needs

• Identified workflows and data collection processes for related quality measures

• Selected specific screening tools

2024-06-26 Page 17 of 111 medical and social risk assessments to drive risk appropriate care

Screening/Referral for

Behavioral Health Needs

• Guidance to analyze gaps in resources to meet behavioral health needs of pregnant and postpartum people in communities within the model test region

• Education on recommended behavioral health screenings and follow up for maternal depression and anxiety or managing existing behavioral health conditions during and after pregnancy

• Guidance to ensure that workflows and quality measures include recommended screening and follow up for maternal depression and anxiety

Screening/Referral for SUD and Tobacco Use

• Guidance to ensure that workflows and quality measures include recommended screening and follow up for tobacco use and substance use disorder.

• Education on recommended screenings and follow-up practices for tobacco use and substance use disorder, including use of the Office of the National

Coordinator Neonatal Abstinence

Syndrome Informational

Resource63

Screening/Referral for HRSNs

• Guidance to analyze gaps in community resources to meet

HRSNs of pregnant and postpartum people

• Guidance to establish reliable bi-directional referral pathways to

• Identified areas of improvement through completed process map

• Drafted implementation plan to address identified gaps

• Trained hospital and provider staff, as appropriate, on selected screening tools

• Established specific follow-up protocol for positive behavioral health screens and behavioral health workforce linkages made

Screening/Referral for SUD and Tobacco Use

• Drafted a process/journey map of existing screening and referral processes for perinatal beneficiaries with

SUD or tobacco use

• Identified workflows and data collection processes for quality measures

• Selected specific screening tools

• Identified areas of improvement through completed process map

• Drafted implementation plan to address identified gaps

• Trained hospital and provider staff, as appropriate, on specific screening tools

• Established specific follow-up protocol for positive

SUD or tobacco-use screens and behavioral health workforce linkages made, where needed

Screening/Referral for HRSNs

• Drafted implementation plan to address identified gaps

• Identified workflows and data collection processes for quality measures

• Selected specific screening tools

• Established bi-directional referral pathways such that providers can connect beneficiaries to CBOs and receive notification when the CBO is engaged

• Trained staff on specific screening tools

• Established specific follow-up protocols for identified needs

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CBOs to address and resolve

HRSNs

• Guidance on HRSN tools that utilize health IT enabled instruments that support interoperability

Increase home monitoring for diabetes and hypertension

• Guidance to analyze and examine Medicaid coverage and reimbursement for home monitoring to ensure Partner

Providers can track and monitor chronic conditions remotely

• Guidance to operationalize the implementation of home monitoring and use of

Cooperative Agreement funding to cover the cost of telehealth platforms or data integration platforms on an ongoing basis, home monitoring, training for self-monitored blood pressure and associated data submission, blood pressure cuffs and/or glucose monitors for Medicaid beneficiaries, as appropriate

• Guidance in partnering with the state’s Public Health Department, MCP or other organization (e.g.

university) in the design and implementation of home monitoring and creating a partnership plan

• Home monitoring implementation support (e.g.

provider and/or patient education)

• Determined whether a SPA or waiver is needed for

Medicaid coverage of home monitoring

• Created a draft partnership plan between the Recipient and public health department, MCP and/or other organization (e.g. university) on the design and implementation of home monitoring, as appropriate

• Completed draft SPA/waiver documents, as needed, and submitted for internal review, as required

• Met with partners, such as the state public health department, MCP and/or other organization (e.g.

university) and updated partnership plan, as appropriate

• Drafted a plan (including information on Medicaid coverage and reimbursement, information for providers on offering and tracking home monitoring services, devices and apps needed) for how to implement home monitoring so that this intervention can be implemented in the implementation phase

Develop

Health Equity

Plan (HEP)

• Provide guidance on the development of the HEP for the model test region through the following activities:

o Analyses to better understand maternal health disparities

• HEP completed and approved by CMS. At a minimum, the HEP should answer the following questions:

o What are the features, obstacles, and demographics of the test region population?

o What is the state of health equity in this region?

2024-06-26 Page 19 of 111 o Identification of specific improvement goals o Tracking progress toward the goals o Expanding on existing health equity-related activities o Addressing data collection/ infrastructure and quality issues

• Assessing state’s compliance with Translation and Non-

Emergency Medical Transport

(NEMT) requirements in section

1902(a)(4)(A) of the Social

Security Act promulgated in 42

C.F.R. § 431.53 and section

1905(a)(31) of the Social Security

Act and promulgated in 42 CFR §

440.170(a) o Which health disparities will be addressed?

o What are the health equity goals to be attained by December 2029?

o What are the health equity goals to be attained by December 2034?

o What strategies will Recipient use to overcome obstacles to equitable care?

o How are leaders in the Recipient and other relevant organizations held accountable for equitable outcomes?

• Submitted a plan to CMS to comply with NEMT requirements, if needed

• Submitted a plan to CMS to comply with translation requirements, if needed

• Established a process for measuring and tracking stratified outcomes in state or sub-state region of interest for conditions with identified disparities

Optional Pillar 1

Cover • Guidance to cover certified To be established during Model Year 1 certified midwives and certified midwives and professional midwives licensed in certified the state through Medicaid professional authorities midwives

• Guidance for completing rate development and payment analyses, as appropriate, that compare the reimbursement rate for all professional midwives, as a proportion of a relevant benchmark rate, for determining fee schedule updates, as appropriate

• Guidance to connect with local and state resources, including

CBOs, community colleges, midwifery training organizations and others to expand recruitment, training opportunities, and marketing around the use and availability of CMs and CPMs

2024-06-26 Page 20 of 111

• Guidance and trainings for all professional midwives to help them enroll in Medicaid and learn about reimbursement structures and billing procedures

• Provider awareness and education on appropriate scope of practice and to create more supportive care environments for

CMs and CPMs to furnish services

Cover • Guidance to cover perinatal To be established during Model Year 1 perinatal CHWs through Medicaid

CHWs authorities

• Guidance for completing rate development and payment analyses, as appropriate, that compares the reimbursement rate for perinatal CHWs, as a proportion of a relevant benchmark rate, for determining fee schedule updates, as appropriate

• Guidance to connect with local and state resources, including

CBOs, community colleges, HRSA-funded Area Health

Education Centers, perinatal

CHW training organizations and others to expand recruitment, training opportunities, and marketing around the use and availability of perinatal CHWs

• Guidance and trainings for perinatal CHWs to help them enroll in Medicaid and learn about reimbursement structures and billing procedures

• Provider awareness and education to create more supportive care environments for perinatal CHWs to furnish services

2024-06-26 Page 21 of 111

• Information to Medicaid beneficiaries about the availability of perinatal CHWs, and benefits of perinatal CHW care

Create • Guidance to bolster regional To be established during Model Year 1 regional partnerships in rural areas among partnerships health centers, Rural Health in rural areas Clinics (RHCs), birth centers, community hospitals and larger hospitals/health systems for risk management

• Guidance on…