Transparency into State Directed Payments Act of 2024

Not later than January 1, 2026, the Secretary shall establish a system for each State to submit a report, at intervals as determined appropriate by the Secretary, on directed payment data, as a requirement for a State plan or a State plan amendment that would provide for a directed payment arrangement.

Each report submitted by a State in accordance with the requirement established under subparagraph (A) shall include the following:

(i) An explanation of how directed payments made under the State plan or a State plan amendment will result in payments that are consistent with section 1902(a)(30)(A), including standards with respect to efficiency, economy, quality of care, and access, along with the stated purpose and intended effects of the directed payment.

(ii) The criteria used to determine which providers are eligible to receive the directed payment.

(iii) A comprehensive description of the methodology used to calculate the amount of, and distribute, the directed payment to each eligible provider, including—

(I) data on the amount of the directed payment made to each eligible provider, if known, or, if the total amount is distributed using a formula based on data from 1 or more fiscal years, data on the total amount of the directed payments for the fiscal year or years available to all providers eligible to receive a directed payment;

(II) if applicable, the specific criteria with respect to Medicaid service, utilization, or cost data to be used as the basis for calculations regarding the amount or distribution of the directed payment; and

(III) the timing of the directed payment made to each eligible provider.

(iv) An analysis of how total Medicaid payments made to an eligible provider, including the directed payment, compare relative to the upper payment limit for such provider and the average commercial rate for the services to which the payment relates.

(v) The net payment rate to a provider receiving a directed payment that is inclusive of base payment rates, supplemental payments (as defined in subsection (bb)), and any such directed payments.

The Secretary shall make all reports and related data submitted under this paragraph publicly available on the website of the Centers for Medicare & Medicaid Services on a timely basis.

In this subsection:

The term directed payment arrangement means a contract arrangement between a State and a managed care organization, prepaid ambulatory health plan, or prepaid inpatient health plan that directs the expenditures of such managed care organization, prepaid ambulatory health plan, or prepaid inpatient health plan in a manner allowable under section 438.6 of title 42, Code of Federal Regulations (or any successor regulation).

The term directed payment means a payment to a provider made pursuant to a directed payment arrangement.

The terms prepaid ambulatory health plan and prepaid inpatient health plan have the meaning given each such term in section 438.2 of title 42, Code of Federal Regulations (or any successor regulation).