Considerations for States Interested in Applying for the States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model
The Centers for Medicare & Medicaid Services (CMS) recently released its latest total cost-of-care model, the States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model, with the goals of slowing growth in health care costs, improving population health, and advancing health equity (see NASHP’s summary of the model here).
Participation will be competitive, with up to eight states selected to participate, across three cohorts. States interested in participating in the model must submit applications by March 18, 2024, for Cohort 1 or 2 and by August 12, 2024, for Cohort 3. Specifics required for the applications can be found in the Notice of Funding Opportunity (NOFO).
As states assess their interest and readiness to pursue the model, there are important governance considerations relating to meeting the requirements of the application and strategically planning for implementation. In addition, states are trying to balance the requirements associated with the model and their broader transformation goals. This blog post summarizes both the governance requirements identified by CMS and additional strategic considerations for states thinking about whether they will pursue the AHEAD Model, as well as states that are applying to ensure they are well-positioned for application, negotiation, pre-implementation, and implementation. This blog post will be part of a series released over the next couple months, highlighting key components of the AHEAD Model for states.
Internal State Structure
Requirements for Applicants
States applying for the AHEAD Model are required to identify the internal structure and governance for the relevant state agencies that will be involved with the Model. Applicant states must identify a lead agency, which may be the Medicaid, public health, state insurance, or other agency with rate setting or budget authority. States may submit a joint application, but a lead agency must be identified that is ultimately accountable for the model. The Medicaid agency does not have to be the lead agency, but if it is not, it must be identified as a sub-recipient as part of the application.
Additional Strategic Considerations
In addition to the requirements laid out by CMS, states are considering how best to structure their internal governance for the model to position themselves for the application process, pre-implementation, and implementation. Such considerations include:
- Who will have decision-making authority throughout negotiation, pre-implementation, and implementation? Will the answer differ for model components? For example, will one agency have authority for hospital global budgets, another authority for primary care?
- Will cross-agency relationships be formalized? Will decision trees and matrices be created? How do these structures support and/or interface with states’ broader transformation goals?
- What internal resources does the state have while preparing the application and awaiting award (e.g., support staff, consultants, etc.)? Who can provide expertise on model components? Who is providing staffing for logistics? Who is interfacing with the legislature, with the public? How will staffing and resources change upon award?
- How will states communicate with interested parties, and how will activities with interested parties be coordinated?
Formal Model Governance Structure
Requirements for Applicants
Applicant states are required to identify a multi-sector formal governance structure to inform model activities, set up within six months of the award. The governance structure may serve an advisory role as it does not have to have ultimate decision-making authority. The structure may build on currently existing boards and workgroups.
The award recipient must work with the governance structure on the following activities (at a minimum):
- Planning for and assisting with model implementation
- Input on the selection of population health, quality metrics, and equity targets
- Developing and producing annual reports on the statewide health equity plan
- Reviewing the hospital health equity plans
- Input on the use of cooperative agreement funding
- Ensuring that implementation is informed by diverse perspectives and providing input on investments and activities to meet quality and cost growth objectives. This may include input on all-payer cost growth and primary care investment targets.
The formal governance structure must include individuals with decision-making authority on model-related activities representing:
- The Medicaid and health agencies, playing a leading role in bringing together interested parties
- Other relevant state agencies with rate setting or budget authority (e.g., Department of Insurance)
- Community-based organizations, patients, and consumers, particularly from underserved communities
- Health care payers, clinicians, and provider organizations, including from underserved communities
- Entities relating to population health (e.g., transportation, food, housing)
- If applicable, rural health and local Tribal health representatives
Additional Strategic Considerations
In addition to the requirements laid out by CMS for the formal governance structure, states should consider how to organize the governance structure to be as useful as possible for the state. When considering members, states may reflect how best to ensure the membership is diverse, balanced, and aligns with the state’s overall goals and that there is the expertise needed on each of the model components. Specific considerations for the structure of the formal governance model may include:
- What structures currently exist in the state? Will the state leverage an existing governance structure or create something new? Balancing these options, creating a new structure can take time and leveraging existing structures means adding new responsibilities to that group and ensuring it meets the requirements of CMS and needs for the model.
- How will the structure be formalized and how will it be made sustainable throughout, and even after, the cooperative agreement?
- What will the governance structure be charged with? Will there be anything in addition to the NOFO minimum requirements (e.g., how are states balancing the CMS requirements and their broader transformation goals)? How can the scope and resources best be prioritized?
- Will there be a charter and/or bylaws? (i.e., agreements on whether the group votes, how it interfaces with state entities, etc.)
- How will additional engagement and input be gathered outside the formal governance structure? (e.g., statewide equity plan, developing and gaining buy-in for the Medicaid hospital global budget methodology)
- How will the governance structure coordinate with other boards and work groups? (i.e., existing health equity structures)
- What staffing and infrastructure is needed from the state agencies?
- What will be the meeting timelines and time commitments of members?
- How will the governance structure’s work be communicated to the public?
Next Steps
NASHP and Mathematica are collaborating on a series of state-only conversations for states interested in AHEAD. The first virtual meeting on December 19, 2023, focused on governance, as described here. The next two virtual meetings focus on additional critical considerations for states as they assess their capacity and readiness for the AHEAD Model: hospital global budgets and Primary Care AHEAD. Participants will have the opportunity to hear from and engage with experts and discuss with their peers in other states key model issues and considerations. Additional virtual meetings will follow. States interested in participating in the virtual meeting series can learn more and register here.
