国会预算办公室-医疗补助国家定向支付：CBO模型的更新（英）

Presentation to the Panel of Health AdvisersSeptember 12, 2025Cyrus Ekland, Claire Hou, Aaron Pervin, and Rajan TopiwalaBudget Analysis and Health Analysis DivisionsMedicaid State-Directed Payments: An Update on CBO’s ModelingFor more information about the panel, see www.cbo.gov/about/panels-advisers, and for the meeting agenda, see www.cbo.gov/sites/default/files/agendas/PHA_Agenda_2025.pdf.1▪ Background on State-Directed Payments▪ The 2025 Reconciliation Act Made Significant Changes to Future SDPs▪ Basis of CBO’s Estimate of the Effects of the SDP Policy▪ Key Questions▪ References CitedRoad Map2Background on State-Directed Payments3▪ State-directed payments (SDPs) are payments that states direct to specific providers through Medicaid managed care organizations.– SDPs are similar to fee-for-service supplemental payments (for example, disproportionate share or upper payment limit payments).▪ States finance most SDPs through provider taxes and intergovernmental transfers.1– Both are permissible forms of Medicaid financing under statute and shift the financing burden from states to the federal government and providers.1,2▪ In 2024, the Centers for Medicare & Medicaid Services (CMS) allowed states to pay providers up to average commercial rates (ACRs) by using SDP authority (2024 Managed Care Rule).3– In a review of SDP applications approved by the end of 2020, the Medicaid and CHIP Payment and Access Commission showed that, in practice, CMS had been allowing states to pay providers above-Medicare rates.4– In 2022, ACRs for hospital services were 254 percent of Medicare rates, on average.5What Are State-Directed Payments?4▪ SDPs grew significantly in recent years and represent a large share of Medicaid spending:– $26 billion in fiscal year 2020 to $102 billion in fiscal year 20244– 8 percent of managed care spending in fiscal year 2020 to 21 percent in fiscal year 2024▪ Although SDPs go mainly to hospitals and nursing facilities, some payments are targeted to other types of providers, such as behavioral health facilities.6How Large Are State-Directed Payments?5The 2025 Reconciliation Act Made Significant Changes to Future SDPs6▪ The 2025 reconciliation act (P.L. 119-21) lowered the limit for SDPs from ACRs to Medicare rates for hospitals, nursing facilities, and academic medical center (AMC)–affiliated physicians.– For states that have expanded Medicaid coverage to low-income adults through the Affordable Care Act, new SDPs are limited to 100 percent of Medicare rates. For states that have not, the limit is 110 percent.– For existing SDP arrangements, payment rates stay at current rates until 2028 and then will be cut by 10 percentage points per year until they reach the limit.▪ CMS retains the authority to approve SDPs at any rate and change payment limits for other types of services (such as primary care services and behavioral health services).The 2025 Reconciliation Act Lowered the Limit for SDPs7▪ The law further limited provider taxes, a major