State Plan Amendments (SPA)
A Medicaid and CHIP state plan is an agreement between a state and the Federal government describing how that state administers its Medicaid and CHIP programs. It gives an assurance that a state will abide by Federal rules and may claim Federal matching funds for its program activities. The state plan sets out groups of individuals to be covered, services to be provided, methodologies for providers to be reimbursed and the administrative activities that are underway in the state.
When a state is planning to make a change to its program policies or operational approach, states send state plan amendments (SPAs) to the Centers for Medicare & Medicaid Services (CMS) for review and approval. States also submit SPAs to request permissible program changes, make corrections, or update their Medicaid or CHIP state plan with new information.
Persons with disabilities having problems accessing the SPA PDF files may call 410-786-0429 for assistance.
State SPA Reporting Requirements and Tools
All states must submit a State Plan Amendment by June 30, 2017, with an effective date of no later than April 1, 2017, to be in compliance with the new reimbursement requirements in CMS’ Covered Outpatient Drug final rule with Comment (CMS-2345-FC).
The following Medicaid SPA processing tools are available for states:
- Medicaid SPA Processing Tools for States
- State Pharmacy SPA Reporting Requirements
- Access to Care
- Tribal Affairs, Guidance & Resources
- Excluded Drugs
State Supplemental Drug Rebate Agreements
A state Medicaid program may obtain CMS approval through a State Plan Amendment (SPA) to enter into single-state and/or multi-state supplemental drug rebate agreement that generate rebates that are at least as large as the rebates set forth in the Health and Human Services Secretary's national rebate agreement with drug manufacturers. For your information, we have compiled a chart that depicts the States with Medicaid Pharmacy Supplemental Rebate Agreements (SRA) with their original effective dates.
Several states have also received CMS approval to enter into value-based purchasing (VBP) supplemental rebate agreements with manufacturers. Such arrangements are intended to allow states to collect supplemental rebates for certain drugs when linked to an observed or expected therapeutic or clinical value in a select population and includes, but is not limited to (1) Evidence-based measures, which substantially link the cost of a covered outpatient drug to existing evidence of effectiveness and potential value for specific uses of that product; and/or (2) Outcomes-based measures, which substantially link payment for the covered outpatient drug to that of the drug's actual performance in patient or a population, or a reduction in other medical expenses.
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Blood Disorders
Specialty blood disorder products are not required to be reimbursed at actual acquisition cost (AAC). When evaluating the adequacy of total Medicaid reimbursement for blood disorder product claims, the professional dispensing fee should be adequate to assure access consistent with 1902(a)(30)(A). Guidance to states concerning Medicaid coverage and reimbursement for clotting factors, anti‐hemophilia drugs and other services provided to Medicaid beneficiaries with blood disorders can be found in the Medicaid Drug Rebate Program Notice, State Release No. 182.
When proposing a change to a reimbursement methodology, state Medicaid programs are required to submit a State Plan Amendment (SPA) to the Centers for Medicare & Medicaid Services (CMS) for review and approval.
Questions regarding the topics on this page? Email RxDrugPolicy@cms.hhs.gov
Disclaimer: Please note that the information provided on this web page does not bind or obligate the Centers for Medicare and Medicaid Services (CMS). The statements included on this web page are intended to provide information on State Prescription Drug Resources and do not in any way revise or modify the requirements set forth in Section 1927 of the Act, the national drug rebate agreement (NDRA), subsequent program releases, or regulations.
Page last updated on December 2, 2024