5 Must-Have Features in a TMAH Developer

During development, a positive tone resist film is structured by a removal of exposed areas, while unexposed areas are removed if negative resists are used. To achieve reproducible results, temperatures between 21 and 23 °C  0.5 °C are highly recommended.

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Allresist offers two different kinds of developers which are either buffered systems (AR 300-26, AR 300-35) or metal ion free (unbuffered) TMAH developers (AR 300-44 … 475):

Developer AR 300-26 is a buffered system with high activity which is preferably used for the development of thick resist films > 5 µm, if high contrast, steep edges, and short development times are desired. Provided as developer concentrate, this developer is diluted with deionised water and can also be used for spray developments.

Developer AR 300-35 is a buffer system with broad process range and particularly characterised by a wide variation range with respect to contrast and sensitivity. This highly versatile developer suitable for most photoresists is provided as developer concentrate which can be diluted with deionised water. The undiluted developer solution is primarily designed for the development of 3 – 6 µm resist films. This developer is suitable for aluminium-containing surfaces, since it does (in contrast to other developers) not attack aluminium.

The developer product line AR 300-40 comprises four metal ion-free developers of various concentrations, which particularly well meet the high demands of micro lithographic applications in semiconductor industry. The use of these developers minimises the possibility of metal ion contamination on the substrate surface. They exhibit excellent netting features and work, as aqueous alkaline solutions, without leaving any residues. The developers are each adjusted to the different resist systems AR-P - and .

Metal ion-free developers are more sensitive to dilution variations than buffer systems. These developers should be diluted very carefully, if possible with scales and immediately prior to use, in order to assure reproducible results.

Higher developer concentrations result in an increased light sensitivity of positive resist developer systems. The required exposure energy is minimised and development time is reduced, allowing a high operational capacity. Possible disadvantages might be a higher dark erosion of unexposed areas and also a low process stability (reaction too fast). Using higher developer concentrations, negative resists require a higher exposure dose for cross-linking.

Lower developer concentrations provide a higher contrast, e.g. of positive resist films, and reduce the resist thickness loss of unexposed or partly exposed border areas even at longer development times. The best contrast values can be obtained with carefully diluted buffered systems (AR 300-26, AR 300-35). In this case, the exposure energy required is mandatorily increased. Negative resists require a lower exposure dose (for cross-linking) at lower developer concentrations. However, the time for complete development is extended. As a rule of thumb for the developer strength: high speed (strong) or high contrast (weak).

The service life of the developing bath for immersion development is limited by factors such as process throughput and CO2 absorption from air. The throughput is dependent on the fraction of exposed areas. CO2 absorption is also caused by frequent opening of the developer bottle and leads to a reduced development rate.

Different methods exist for the development:

Immersion development: The wafer is completely immersed in a bath and move.

Puddle development: A defined amount of the developer is placed on the wafer, the wafer is then gently turned back and forth.

Spray development: The developer is sprayed through nozzles onto the rotating wafer. This development is significantly faster than other methods.

No interruptions should occur during aqueous alkaline development. If wafers are rinsed with water after development and the development is then continued, development rates will increase significantly.

FAQ Topics:

• Application
• Funding
• Model Elements
• Regional Plan
• Payment Model
• Other

Application

1. Who was eligible to apply to participate in the TMaH Model?
   
   State Medicaid agencies selected to participate in the TMaH Model were required to meet the following criteria:

• Be a state Medicaid agency in the 50 states, District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, or the Commonwealth of the Northern Mariana Islands.
• Have an average number of combined Medicaid-and-CHIP-covered births between calendar years - of no less than 1,000 per year for the selected implementation region. 
  
  Please note that states participating in the Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model may only participate in the TMaH Model if each model is implemented in non-overlapping substate regions. Please refer to the Overlaps Policies Factsheet (PDF) for more information.  

2. What types of technical assistance are available to states and providers to help implement TMaH?
   
   Each awarded state Medicaid agency will receive 3 years of tailored technical assistance (TA), in one-on-one and group settings, from a team of policy and analytic experts. During the first quarter of the Pre-Implementation Period, a TA plan will be drafted collaboratively with the SMA awardee, CMS Innovation Center, and contracted TA coach.
   
   The goal of the TA plan is to identify each awardee’s needs and to establish the right readiness steps to successfully implement the TMaH care delivery and payment model.
   
   Topics may include:

• Quality measures
• Data analytics
• Payment model design and methodology
• Partnering with perinatal quality collaboratives and community-based groups|
   

3. How much funding is available to support SMAs in achieving requirements?
   
   Each awarded state Medicaid agency is eligible for up to $17 million dollars during the model’s 10-year period.
    
4. How were states selected to participate in the TMaH Model? 
   
   State Medicaid agencies interested in participating in the model submitted a completed application during the Notice of Funding Opportunity (NOFO) application period. There was  a competitive application process, including a merit review of all applications. The merit review panel scored applications using a detailed rubric, which was available to all applicants as part of the NOFO. 
    
5. Will there be more than one opportunity for states to apply? 
   
   No, only one NOFO application period is currently planned.
    
6. How can providers in an awarded state participate in the model?
   
   State Medicaid agencies will work directly with a variety of stakeholders and providers to implement aspects of the model.  When the payment model begins, providers will need to be contracted with a managed care entity or directly with the Medicaid agency in a fee-for-service setting in the region that will be implementing the TMaH Model.
    
7. Will this model qualify as an Advanced or MIPS Alternative Payment Model (APM)
   
   TMaH is a Medicaid model and therefore is not an Advanced APM nor a MIPS APM.
    
8. What information was TMaH Model applicants be required to provide?
   
   State Medicaid agencies interested in submitting a Notice of Funding Opportunity (NOFO) application were asked to provide the following:

• An assessment of applicant’s readiness to implement TMaH Model components, which include factors such as: maternal health policy priorities, capacity, payment environment, regional plan, status of model pillars, sustainability plan, stakeholder recruitment plan, Tribal engagement, safety net provider partnerships, including with birth centers and community-based organizations.
   
• A detailed budget, including a budget narrative. 
   
• Resumes, job descriptions, and organization chart for required model staff
  
  The merit review and selection process are outlined in the NOFO. CMS will consider the geographic diversity, program priorities, and quality of all applications when making final award determinations. Please refer to the NOFO for full application requirements. CMS will select up to 15 recipients at CMS’ sole discretion. 
   

9. Were organizations or businesses permitted to apply to the TMaH Model?
   
   No. Only state Medicaid agencies (SMAs) were permitted to apply for the model.  CMS encourages any organizations interested in the TMaH Model to partner with their SMA to support implementation.
    
10. Did a state need to be a Medicaid expansion state in order to apply?
    
    No. States did not need to have expanded Medicaid to everyone with a household income below a certain level to apply.
     
11. Did a state Medicaid agency need to expand Medicaid coverage to 12 months postpartum to apply or participate in the TMaH Model?
    
    No. A state Medicaid agency (SMA) was not required to extend Medicaid coverage to 12 months postpartum. CMS strongly encourages SMAs to extend Medicaid coverage to 12 months postpartum and will offer technical assistance as needed.
     
12. When was the TMAH Model application be available?
    
    CMS released a Notice of Funding Opportunity (NOFO) for the TMaH Model on June 26, . CMS accepted applications until September 20, . CMS  announced the recipients selected to participate in the model in January .
     

13. What are the criteria used to select award recipients?
    
    A panel of merit reviewers assessed and scored applications based on the criteria outlined in Section E.1 of the TMaH Model Notice of Funding Opportunity (NOFO). Applicants were encouraged  to pay particular attention to TMaH Model NOFO Sections A.4 Program Requirements and D. Application and Submission Information. The merit reviewers assessed and scored applications using a scale of 100 total base points.

    The Project Narrative was worth 80 points. In the Project Narrative, applicants  addressed their state’s maternal health policy priorities, organization, administration and capacity, payment environment, intended regional plan, status of model pillars, sustainability plan, and stakeholder recruitment plans. The Budget Narrative was worth 20 points. In the Budget Narrative, applicants provided a detailed budget with justification. All elements of the Project Narrative and Budget Narrative were used to assess an applicant’s ability to design and implement an intervention that aims to improve maternal health outcomes.

Funding

1. Can funds distributed to the state Medicaid agencies through the TMaH Model be used to pay current staff or hire staff to carry out work for the model?
   
   Yes, state Medicaid agencies may use model funds to hire personnel to support model implementation. As part of the application process, applicants will be required to submit a detailed budget that explains how the position will support the implementation of the model. Budgets are subject to CMS review and approval.

   If the staff person has duties unrelated to the TMaH Model, the state Medicaid agency must ensure the staff person properly accounts for his or her time and effort for separate tasks: implementation (model activity) and other duties as assigned (non-model activity). The state Medicaid agency must take care to avoid using TMaH Model Cooperative Agreement funding for non-model duties. The state Medicaid agency may not use TMaH Model Cooperative Agreement funds to cover the portion of a staff person’s time spent fulfilling other duties as an employee of a state Medicaid agency nor may the state Medicaid agency receive Medicaid reimbursement for the portion of time the staff member is working on model activities and is being reimbursed through Cooperative Agreement funds.

2. How can Cooperative Agreement funding be used?
   
   State Medicaid agencies selected to participate in the TMaH Model will receive up to $17 million in Cooperative Agreement funding over 10 years. 

   Specific parameters around how these funds can be used are included in the Notice of Funding Opportunity (NOFO). Generally, funding is intended to support model planning and implementation activities, including but not limited to: 

• Developing partnerships with maternal health clinical and non-clinical providers
• Hiring new staff to support the model
• Training related to the model
• IT infrastructure investments
• Supporting data collection
   

3. How much money is available to state Medicaid agencies? Are there any matching requirements that the state should be aware of?
   
   Each state Medicaid agency is eligible for up to 17 million over the 10-year period of performance of the model. Award amounts may vary based on factors such as the size and needs of Medicaid and CHIP populations to be served by the model, as well as the overall scope of project as described in the application.
   There are no matching requirements for the TMaH Model. 
    
4. Is cooperative agreement funding to a state Medicaid agency reduced if it has already implemented a required model element? For example, if a state Medicaid agency already covers doula services, will it receive less funding than another state that does not cover doula services, all else being equal? 
   
   No. Funding is not tied to prior achievement of specific model element requirements. Every application requires state Medicaid agencies to submit a detailed budget narrative. The budget narrative must clearly define the proportion of the requested funding designated for each activity and justify the applicant’s readiness to receive funding. Each activity must be clearly linked to the model milestones and be consistent with model requirements. Funding amounts will be based on the submitted budget narrative, up to the defined limit, subject to CMS approval. Cooperative agreement funding may not supplant any existing funding stream.
    

5. May state Medicaid agencies disburse a portion of their cooperative agreement funding to managed care plans (MCP) to support MCP-level infrastructure and capacity building for the TMaH Model?  

   Yes, state Medicaid agencies (SMAs) may disburse a portion of their Cooperative Agreement funding to MCPs to support infrastructure and capacity building for the TMaH Model, subject to CMS approval. SMAs should provide a description and details on how they propose to use Cooperative Agreement funding in their budget narrative.
    

Model Elements

1. How does CMS see this effort intersecting with state Medicaid work on Health-Related Social Needs?
   
   At a minimum, the TMaH Model will require reporting on screening for three domains of health-related social needs (HRSN): food insecurity, housing instability, and transportation. The TMaH Model will require use of a validated health IT-encoded HRSN screening instrument  such as the Accountable Health Communities HRSN Screening Tool, unless a specific instrument is required by state law.
2. How will the state Medicaid agency work with state Perinatal Quality Collaboratives as part of the TMaH Model?
   
   CMS understands that state Medicaid agencies (SMAs) and the Perinatal Quality Collaboratives (PQCs) have different relationships in different states. It will be important to strengthen those relationships to ensure that SMAs are aware of the Alliance for Innovation on Maternal Health (AIM) safety bundle work that’s being proposed to implement in hospitals, and can support PQCs, hospitals, and providers with implementation while being careful not to duplicate or supplant any funding that might be in place through Health Resources and Services Administration (HRSA), American College of Obstetricians and Gynecologists (ACOG), Centers for Disease Control and Prevention (CDC) or some other entity. As with many of the model interventions, circumstances will vary by state, and CMS will provide technical assistance to help states make those connections.
    
3. How will the TMaH Model address perinatal mental health conditions, screening and treatment?
   
   Screening and referral for behavioral health needs is a model requirement. Providers may use provider infrastructure payments to support their engagement with community-based organizations that can help address health-related social needs and behavioral health needs of beneficiaries and integrate them into screening, referral and follow-up activities.
   
   During Model Year 4, a depression screening and follow-up measure will be included in the calculation of performance incentive payments to providers to increase the number of Medicaid and CHIP beneficiaries who are screened for clinical depression and who, if screened positive, received follow-up care during the prenatal and postpartum period.
    
4. Will there be a patient survey involved with the TMaH Model?
   
   Yes. CMS plans to assess whether the model influences women’s experience with maternal care, especially for underserved communities with historically poorer outcomes. CMS is still researching emerging options in this space, but we do expect to include a patient-reported outcome or patient-reported experience measure (PREM).
    
5. Will doula services be covered through the TMaH Model?
   
   Yes. There is significant evidence that incorporating doula services in a patient’s care team can improve outcomes across a range of conditions and circumstances. Therefore, participating state Medicaid agencies will be required to cover doula services by the end of Model Year 3 under the TMaH Model.
    
6. Does the TMaH Model intend to increase access to midwives other than certified nurse midwives?
   
   Coverage for certified nurse midwives is required by Medicaid. With the assistance of the TMaH Model, each state Medicaid agency (SMA) will be required to assess their current levels of coverage with a goal to improve access to midwifery care. Possible strategies may include revising how midwives are paid or reducing the administrative burden for timely payment. CMS is not requiring that SMAs add new midwife certification categories. However, if a SMA is interested in covering other licensed midwives, like certified midwives and certified professional midwives, the model will offer technical assistance to assist them with the process.
    
7. How does the TMaH Model support maternal health in rural areas?
   
   The model aims to increase access to care by broadening the maternal health workforce and advancing the use of telehealth. This effort can provide additional support to women with conditions such as gestational diabetes or hypertension. Additionally, state Medicaid agencies may elect to receive technical assistance to advance home visiting, mobile clinics, or regional partnerships in rural areas among birth centers, health centers, community hospitals, larger hospitals/health systems and community-based organizations.
    
8. What technical resources does CMS provide for state Medicaid agencies to successfully implement the TMaH Model?
   
   CMS will provide rigorous one-on-one tailored policy and analytic technical assistance (TA) to help state Medicaid agencies (SMAs) meet a list of milestones for each element by the end of the 3-year Pre-Implementation Period. We understand that SMAs may be at different starting points for each model element, and that the TA needs to be specific for their unique circumstances. In addition to one-on-one TA, CMS will offer opportunities for peer-to-peer engagement and group learning. More information about the TA can be found in the Technical Assistance Factsheet (PDF) available on the TMaH Model web page.
    
9. Is the TMaH Model a care delivery model or a payment model?
   
   The TMaH Model is both a care delivery and payment model. During the 3-year Pre-Implementation Period, state Medicaid agencies (SMAs) and partners will be working to develop care delivery infrastructures – such as doula services, comprehensive screening and referral pathways and building partnerships with community-based organizations to address health-related social needs – and then establishing a process for advancing an innovative payment approach. No later than Model Year 3, SMAs will use a portion of cooperative agreement funding to pay providers for care delivery and infrastructure changes. SMAs will transition to upside-only payments for a set of quality and cost benchmarks based on Model Year 4 performance, leading into a longer-term, value-based payment approach that CMS, in collaboration with SMAs, will design and structure during the 3-year Pre-Implementation Period.
    
10. Is there a limit to the number of optional elements a state Medicaid agency may select to implement?
    
    No, there is no limit on the number of optional elements that a state Medicaid agency (SMA) may select to implement. CMS recommends that a SMA consider its current population health goals, maternal health care delivery system, partnerships and any other state-specific factors when choosing optional elements. The selection of optional elements will not affect a SMA’s score in the application review process.
     
11. Can you explain the workforce development component of the TMaH Model?
    
    The TMaH Model provides technical assistance and Cooperative Agreement funding to state Medicaid agencies (SMAs), to expand the maternal health workforce. In particular:

• The TMaH Model will support SMAs in covering doula services through Medicaid authorities, including defining doula services and guidance on calculating appropriate reimbursement rates for these services. CMS will help SMAs establish a State Doula Support Council to expand opportunities and to guide implementation. CMS will provide technical assistance to states to support recruitment, training opportunities, and communications related to the use and availability of doula services.
• The TMaH Model will also support SMAs in assessing their midwifery workforce capacity and offer the option to expand coverage of licensed midwives in the state. CMS will support payment analyses to develop and update a fee schedule and for the creation of billing pathways that allow both midwives and obstetricians to consult with maternal-fetal medicine specialists. The model will help connect SMAs with local and state resources to expand recruitment, training opportunities, and patient communication about the use and availability of midwives.
• SMAs may also choose to cover optional services such as perinatal community health workers (CHWs), lactation consultants, etc. In these instances, the model will provide additional guidance to SMAs to cover perinatal CHWs through the appropriate Medicaid authorities.
   

14. What options exist for state Medicaid agencies to cover doula services through the TMaH Model?
    
    States can cover doula services using their Medicaid authority, typically through a State Plan Amendment. As a part of participation in the model, states will receive guidance on covering doula services, including how to define doula services, how to develop doula rate benchmarks, how to establish a State Doula Support Council to advise the state on best practices for expanding access to Doula Services, and guidance on connecting with local and state resources that may already be in place.
     
15. Are state Medicaid agencies required to adopt birth center licensure?
    
    No. States have different licensing entities and processes, and as such state Medicaid agencies are not typically responsible for licensing birth centers. If birth centers are or are desired to be licensed in the state, technical assistance would be provided to state Medicaid agencies to understand Medicaid coverage of birth centers, potential birth center reimbursement rates and processes, and other relevant activities spelled out in more detail in the TMaH Model Notice of Funding Opportunity.
     
16. If a state Medicaid agency or other state agency does not license birth centers, do the birth center requirements still apply?
    
    Yes, the birth center requirements would still apply even if a state does not license birth centers. The aim of the model is for birth centers in the state to receive payment commensurate with their services. As part of technical assistance, CMS would help a state explore possible pathways for Medicaid reimbursement.
     
17. We don’t have birthing centers in our state; may we still apply for this model?
    
    Yes. Medicaid is required to cover deliveries at licensed birth centers in all states, but not all states license birth centers. CMS will require that the state Medicaid agency examine potential Medicaid coverage requirements, reimbursement rates and processes, and other relevant activities included in the TMaH Notice of Funding Opportunity to determine feasibility of establishing birth centers. These studies would be applied if birth centers were to open in the state at some point during the TMaH Model.
     
18. May a state Medicaid agency propose to implement some TMaH Model “pillars” statewide and others regionally?
    
    State Medicaid agencies must identify the test area for the TMaH Model – which can encompass the entire state or a sub-state region. All elements of each pillar must be implemented within the test region. CMS understands that:

• Some model elements may already exist statewide and will continue to exist statewide even if the test region is limited to a sub-state region. In a sub-state implementation, any enhancement or expansion of elements funded by the TMaH Model Cooperative Agreement – and not Medicaid covered services – must be exclusive to the test area.
• For example, the requirement to establish Medicaid payment for doula or other optional Medicaid-covered services, as well as other potential coverage or payment changes, may be implemented statewide using the appropriate Medicaid authorities, regardless of the proposed test area configuration.
   

19. What is the plan for providing technical assistance to state Medicaid agencies regarding expansion of midwifery workforce?
    
    CMS will provide technical assistance to help all state Medicaid agency prepare to implement the TMaH Model. CMS and its contractors will comprise a multidisciplinary technical assistance team to assist the state Medicaid agency, as needed. During the first quarter of the Pre-Implementation Period, CMS and state Medicaid agency will collaborate to draft a technical assistance plan. The plan will identify workstreams, goals, entities to participate in technical assistance and team leads. It will estimate the time required per month by state Medicaid agency and other team members. The plan will specify group or tandem topics to be covered together, and a timeline of milestone activities to be accomplished during Pre-Implementation Period. The technical assistance plan will be revised as needed throughout the Pre-Implementation Period.
     

20. What doula care services will be covered in the TMaH Model?
    
    Doula Services are emotional, physical, and informational support provided by a nonclinical trained professional during pregnancy, delivery, and after childbirth. Doula services established under the TMaH Model must include, but are not limited, to the following:

    For more information, please visit TMAH Developer.

    Prenatal

• Promoting health literacy and understanding of the normal process of pregnancy and fetal development
• Assisting with the development of a birth plan
• Supporting personal and cultural preferences around childbirth
• Providing emotional support and encouraging self-advocacy
• Reinforcing practices known to promote positive outcomes such as breastfeeding
• Coordinating referrals or linkages to community-based support services to address health-related social needs
  
  Labor and Delivery
• Providing physical comfort measures, information, and emotional support
• Advocating for beneficiary needs
• Being an active member of the birth team
  
  Postpartum
• Education regarding newborn care, nutrition, and safety
• Supporting breastfeeding
• Providing emotional support and encouraging self-care measures
• Supporting individuals in attending recommended medical appointments
• Coordinating referrals or linkages to community-based support services to address health-related social needs
   

21. Are all the milestones to complete by the end of model year 3 required?
    
    Yes, the Pre-Implementation Period milestones must be complete by the end of model year 3. The milestones for both required and optional model elements are listed in Table 3 of the TMaH Model Notice of Funding Opportunity. CMS funding and technical assistance will support state Medicaid agencies’ achievement of the milestones. To accomplish this goal, CMS and each state Medicaid agency will collaborate to conduct a needs assessment and create a detailed technical assistance plan at the beginning of the Pre-Implementation Period. For some model elements, state Medicaid agencies will have to engaged closely with Partner Providers, Partner Care Delivery Locations, Partner Organizations, and managed care plans to meet the milestones.
     

Regional Plan

1. For state Medicaid agencies (SMAs) interested in implementing the TMaH Model in a substate region, does the substate region need to comprise a contiguous area, or do SMAs have flexibility to design a substate group with geographic representation across the state?
   
   SMAs may choose a region of their state with demonstrated poor overall birth outcomes or high levels of disparities in outcomes among subpopulations. The region can comprise counties or zip codes and should consider overlapping managed care organization (MCO) coverage in the region (if relevant), mirroring the MCO’s catchment area to the extent possible.
   
   The region does not need to be contiguous as long as an appropriate comparison region can be identified (which also does not have to be contiguous) and the SMA has the resources to implement the entire model simultaneously across the entire chosen region. SMAs choosing regional implementation should propose a comparison region in their application that is similar in demographic composition, resource availability, and population size and density and where they expect to have little or no service overlap.
    
2. For state Medicaid agencies interested in implementing the TMaH Model statewide, it may be difficult to define an out-of-state comparison group that has similar demographic composition, resource availability, population size and density, birth outcomes and Medicaid policies. Would CMS consider an alternative, such as allowing a state to leverage its own historical data as a comparison group or allowing a phased statewide implementation with a pre/post or concurrent comparison group?
   
   No, constructing self-state comparison groups based on historical data is not allowed. CMS cannot control for temporal, environmental, and demographic influences using historical data that may not be historically similar to current controls.
    
3. Is an entire state required to participate in the TMaH Model? 
   
   The TMaH Model may operate statewide or in a substate region. For evaluation purposes, substate implementation is strongly preferred. CMS understands that in some states and territories the minimum number of births may not occur in any substate region; therefore, certain states or territories may need to implement the model state- or territory-wide to meet the 1,000 birth a year minimum.
    
4. For purposes of the Model evaluation, may a state Medicaid agency propose for comparison a state that is participating in a separate model where overlap is not allowed?
   
   Because several CMMI models are in the application phase, states may not be aware of potential overlaps. Therefore, state Medicaid agencies proposing to implement the model statewide are asked to include three alternative comparison states in their application to assist in the evaluation of the TMaH Model. These three states should be similar to their state based on demographic composition, resource availability, population size and density, birth outcomes, and Medicaid policy. Because no single state will be a perfect comparison to the participant state, the CMS evaluation team will use the comparison states proposed by the applicant as a starting point in determining the appropriate comparison state or group of states. For more information on the Regional Plan, refer to TMaH Model Notice of Funding Opportunity Section D.3.1.4.
    
5. If a state Medicaid agency proposes to implement the model in a sub-state region, must the comparison region also contain a minimum of 1,000 annual births?
   
   Yes, both sub-state test and comparison regions should include the minimum 1,000 average Medicaid and CHIP annual births requirement. If multiple non-contiguous regions must be used in aggregate to create one collective “comparison group,” this “collective grouping” must have at least 1,000 Medicaid and CHIP births per year.
    
6. For the 1,000 births a year, if a region/zip codes are chosen, do the 1,000 + births physically need to take place in the area, or do the 1,000+ pregnant women need to have a home address in the area?
   
   The minimum number of births requirement is based on where care is provided, not on beneficiary residence.
    

7. What information is required for the application when seeking to implement the model statewide? Could you provide details on the proposed out-of-state comparison states in the Regional Plan section of the application?
   
   For statewide implementation, details are only needed for the applicant state, not for the comparison states. For more information on the Regional Plan, refer to TMaH Model Notice of Funding Opportunity Section D.3.1.4.

   State Medicaid agencies choosing statewide implementation should propose at least three other states that they believe are comparable in demographic composition, resource availability, population size and density, birth outcomes, and Medicaid policy. Statewide applicants only need to list three states they believe are similar. State Medicaid agencies do not need to provide details of the proposed comparison states. Statewide applicants should suggest these three comparison states based on familiarity with similarly situated peer states and publicly accessible sources. Additionally, statewide applicants need not know if the proposed comparison states are participating in models.
    

8. Is it acceptable to propose a "staggered start" where some state regions would start implementing the model at different times vs. having the regions assigned as either test or comparison?
   
   No. State Medicaid agencies can consider either a full state implementation or a sub-state implementation. For purposes of this model test, state Medicaid agencies must start the model across the whole test region (sub-state or full state) at the same time. If elements of the model are successful and the state wants to expand them to other in-state regions, precluding the use of model funding, they are welcome to do so. However, they cannot implement model interventions in the comparison regions, as this would contaminate the comparison sample.
    
9. May a state Medicaid agency select only one managed care plan (MCP) to implement the model if more than one MCP covers the test region?
   
   No. If more than one MCP covers the test region, all MCPs in that test region must participate in the model. If the selected test region only includes one MCP, then the single MCP may be included.
    
10. Is the minimum requirement of 1,000 average annual births between - based on Medicaid claims data or could the estimate be based on an All-Payer Claims Database or an Electronic Health Record dataset?
    
    The minimum number of births must be based on Medicaid and CHIP accessible claims. Regardless of the size of the chosen implementation area, the average number of combined annual Medicaid- and CHIP-covered births between calendar years - must be no less than 1,000 for the region. This is true for both the intervention and comparison regions.
     

11. The TMaH Model Notice of Funding Opportunity (NOFO) states that the test region may be non-contiguous. May a state Medicaid agency choose multiple test regions whose populations differ on demography, rurality, or resource availability, if we identify a comparator region for each?
    
    No. The TMaH Model NOFO requires that the state choose a test region and a comparison region. It is expected that the test region, whether geographically contiguous or non-contiguous, comprises a population that is largely or overall similar in demographics, population density, and health resources. A test area, whether geographically contiguous or non-contiguous, that includes vastly different population characteristics should not be considered one region.

    For either statewide or sub-state implementation plans, the comparison region must be similar to the test region across demographic composition, resource availability, and population size and density, and may be geographically contiguous or non-contiguous.
     

12. If a state Medicaid agency can choose to implement the model statewide or in a sub-state region, why does the Notice of Funding Opportunity state, "sub-state implementation is strongly preferred for evaluation purposes?”
    
    Based on our experience at the Innovation Center, sub-state models tend to be more evaluable and more likely to have adequate funding. State Medicaid agencies are encouraged to apply with an implementation plan that makes sense for their specific circumstances and provide adequate justification and budget information outlining how they will implement the model statewide or in a sub-state region.
     

13. The TMaH Model Notice of Funding Opportunity Section D. 3.1.4 requests information on “FWHCs providing prenatal care” but does it mean FQHCs?

    Yes, FWHC is a typo and the correct acronym in that section is FQHC. Applications should provide information on Federally Qualified Health Centers (FQHCs), as requested in that section.
     

14. Do state Medicaid agencies need to provide the information requested under TMaH Notice of Funding Opportunity Section D.3.1.(4) for both the test region and the comparison region?  

    For Section D.3.1(4)(e)(i), the number of Medicaid/CHIP births for women aged 15-45 years is required for the test region and the comparison region, if a sub-state comparison region is being proposed (to make sure both meet the 1,000 birth/year minimum).

    For Section D.3.1(4)(e)(ii), the information about health care providers contracted to care for Medicaid and CHIP beneficiaries is required only for the test region in a sub-state implementation. This information is required statewide for statewide implementation.
     

15. May a state Medicaid agency have different intervention and control birthing facilities within the test region?

    No. Intervention and comparison populations should live in separate ZIP codes or counties and should not be expected to have meaningful service overlap, including services outside of the hospitals or birth centers in the area. The regions may be close together (e.g., both within a large metropolitan area) as long as the populations are separated enough that patients will primarily use clinical and other services only within their designated area.
     

Payment Model

1. May a state Medicaid agency participate in the TMaH Model if it is currently operating a non-CMS maternal health value-based payment model in its Medicaid and/or CHIP program? How much flexibility will a state Medicaid agency have with the design and implementation of the alternative payment model for TMaH?
   
   Yes, a state Medicaid agency (SMA) may participate in the TMaH Model if it is participating in an existing value-based payment model; however, a SMA will be expected to align with the TMaH Model payment approach. Please visit the Payment Design Factsheet (PDF) for additional details. CMS will develop a process for engaging SMAs and other key audiences in structured discussions about the Model Year 5 value-based payment design during the 3-year Pre-Implementation Period.
   
   The purpose of these conversations will be to share information with SMAs on CMS’ approach to value-based payment design, and to gain insights from states and other key audience on key features and flexibilities. CMS will individually review state requests to implement the payment approaches earlier than the timeline described in the aforementioned factsheet.
    
2. During which model years can state Medicaid agencies offer Provider Infrastructure Payments?
   
   State Medicaid agencies must use a portion of their Cooperative Agreement funding to disseminate Provider Infrastructure Payments to Partner Providers and Partner Care Delivery Locations for at least one year, beginning no later than quarter 1 of model year 3. State Medicaid agencies may make these payments for more than one year at the state’s discretion. Please note that state Medicaid agencies will not receive additional funding beyond the annual cap as listed in the TMaH Model Notice of Funding Opportunity Table 6.
    
3. Which Partner Providers and Partner Care Delivery Locations can receive Provider Infrastructure Payments? Can they go to any Partner Provider or Partner Care Delivery Locations listed in the TMaH Model Notice of Funding Opportunity or can payment only go to the attributed provider associated with the first prenatal encounter? If the latter, can more than one provider have an attributed beneficiary?
   
   All Partner Providers and Partner Care Delivery locations in the test region that have agreed to implement the activities described in TMaH Model Notice of Funding Opportunity Section A.4.3.1 are potentially eligible to receive the Provider Infrastructure Payments. CMS will share the precise attribution methodology during the Pre-Implementation Period. Allowances regarding attribution of a beneficiary to more than one provider will be determined in partnership with state Medicaid agencies.
    

4. How will CMS determine the amount of the Provider Infrastructure Payments?
   
   CMS will provide technical assistance to states on the methodology for determining the Provider Infrastructure Payment amount and necessary supporting data analyses. The amount requested by states specifically for Provider Infrastructure Payments will be based on the number of participating Partner Providers and Partner Care Delivery Locations in the test region and the estimated average risk-adjusted per member per month amount, using historic data as a baseline.

   Funding for Provider Infrastructure Payments will be available at the beginning of the model year to state Medicaid agencies with approved budgets who have qualified for non-competing continuation Cooperative Agreement funding. State Medicaid agencies must execute a legal agreement (subaward) with a subrecipient(s) for the purpose of administering Provider Infrastructure Payments Such subrecipients may include a managed-care entity, foundations, or another entity dispersing payments to providers and Partner Care Delivery Locations. For more information on Provider Infrastructure Payments, refer to TMaH Model Notice of Funding Opportunity Section A.4.3.1.
    

5. May a state Medicaid agency exclude Fee-For-Service providers from model implementation in a managed care state?
   
   Yes, this will be at the state Medicaid agency’s discretion and subject to CMS approval.
    
6. May a state Medicaid agency implement a value-based payment prior to model year 5?
   
   CMS will work with state Medicaid agencies (SMAs) and other key audiences in structured discussions about the TMaH payment model during the 3-year Pre-Implementation Period. The purpose of these conversations will be to share information with SMAs on CMS’ approach to value-based payment design, and to gain insights from states and other key audiences on critical features and flexibilities. CMS will individually review and grant state requests to implement the TMaH payment model earlier than the timeline described in the Notice of Funding Opportunity on a case-by-case basis.
    
7. Given that state Medicaid agencies are at varying levels of implementation of value-based payment arrangements (e.g., ACO programs) and maternal health initiatives (e.g., doula services, pay parity for certified nurse midwives), is the TMaH Model intended to support state Medicaid agencies that are in a more nascent stage in either or both these areas?
   
   States at different and varying levels of implementation of the required or optional model elements are welcome to apply to participate in the TMaH Model.
    
8. Will the state Medicaid agency determine amounts and processes for its subrecipients to receive Provider Infrastructure Payments or will CMS dictate amounts per provider connected to the attributed population?
   
   CMS will develop the methodology for calculating the risk-adjusted Provider Infrastructure Payments and a floor for payment amounts but will allow states flexibility in determining the exact amount, subject to CMS approval. State Medicaid agencies must execute a legal agreement (subaward) with a subrecipient(s) for the purpose of administering Provider Infrastructure Payments. Such subrecipients may include a managed-care entity, foundations, or another entity dispersing payments to providers and Partner Care Delivery Locations.
    

9. May applicants propose to include only community birth settings (birth centers and home birth) in the TMaH Model care delivery and payment model?
   
   No. The TMaH Model is designed to test interventions in both hospital and birth center settings. State Medicaid agencies must advance each required model element and achieve the Pre-Implementation Milestones listed in TMaH Model Notice of Funding Opportunity Table 3 by the end of model year 3, including those that apply exclusively to hospitals.

   Please also note that CMS requires that in the test region the average number of combined annual Medicaid- and CHIP-covered births between calendar years - must be no less than 1,000. This requirement is based on an assumption that the majority of Medicaid-covered births in the test region will be attributed to the model. Therefore, applicants should consider the number and size of Partner Providers and Partner Care Delivery Locations participating in the model. Also important to note is the requirement that all managed-care organizations operating in the test region are required Partner Organizations.
    

10. Will CMS design the value-based payment that state Medicaid agencies (SMAs) must implement or will states work with CMS to design state-specific methodologies? Will all SMAs implement the same value-based payment arrangement?
    
    CMS will be leading the design of the TMaH payment model that SMAs are then expected to implement. We will work closely with SMAs and other key interested groups, such as providers, to gather input and feedback during the design of the TMaH payment model during the first three years. The TMaH payment model will also be informed by the infrastructure payments, quality and cost performance incentive payments, and the latest research on maternity value-based payment arrangements. Understanding that states will have different policy contexts and constraints, CMS will also allow for some flexibility in the TMaH payment model details and implementation strategy.
     

11. Will state Medicaid agencies have to recognize Doulas as a provider billing type?  

    No, state Medicaid agencies are not required to recognize a new provider type. However, state Medicaid agencies are required to establish coverage and payment for Medicaid and CHIP benefits that are required under the TMaH Model, such as Doula Services. CMS will offer technical assistance regarding how to cover and pay for these services, even if the state does not recognize doulas as a provider type, at sufficient scale to successfully implement the model’s team-based approach. For a list of Doula Services, please refer to the TMaH Model Notice of Funding Opportunity Appendix VII.
     

12. May a state Medicaid agency cover Doula Services through value added benefits?  

    Value-added benefits are extra benefits that managed care plans offer beyond the services covered by Medicaid. State Medicaid agencies will be expected to cover all Doula Services using their Medicaid authority such as through a State Plan Amendment (SPA) or a waiver. State Medicaid agencies should describe any potential obstacles to adding Doula Services as a new Medicaid benefit, such as legislative calendars or staff capacity and corresponding mitigation strategies in their application. Such mitigation strategies could include temporary coverage of doula services as a value-added benefit within the test region, if such temporary coverage is part of a plan leading to a permanent SPA. State Medicaid agencies must have submitted, or have a timeline and process in place, for submitting and implementing a SPA/waiver to cover Doula Services, if not already covered, by the end of the Pre-Implementation Period. As a reminder, CMS will provide technical assistance during the Pre-Implementation Period to help state Medicaid agencies meet milestones.
     

13. Do the Quality and Cost Incentive Payments need to be administered through a subrecipient?  

    No. A state Medicaid agency may decide how to disburse the Quality and Cost Incentive Performance Payments to Partner Providers and Partner Care Delivery Locations. As a reminder, in Model Year 4, Partner Providers and Partner Care Delivery Locations will become eligible for upside-only performance payments to be paid by the state Medicaid agency using the appropriate Medicaid authority and following CMS review. 
     

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