Department of Social Services sets Sept. 1 launch for maternity case-rate bundle, outlines attribution rules

The Department of Social Services (DSS) told participating providers on a stakeholder call that it plans to launch a maternity case-rate payment program on Sept. 1, 2024, and described how case-rate payments will be triggered, attributed and reconciled.

Brad Richards, chief medical officer and medical director at the Department of Social Services, said the program is “gearing up” for a Sept. 1 launch and that DSS will post materials and recordings on its website. Charles (Mercer), the actuary on the call, said the case-rate document distributed to providers is draft and that DSS will re-create case rates in June using a more recent claims dataset to avoid unusual pandemic-era patterns.

Why this matters: the new payment method shifts payment for maternity professional services from per-visit fee-for-service to a monthly case rate once a trigger code is billed, with downstream reconciliation against a target price. That changes how provider groups bill and how revenue is recognized for episodes that span multiple providers.

Key mechanics explained on the call
- Trigger codes and attribution: DSS will consider professional claims that include a published trigger code to start a case-rate payment for the attributed TIN; the full trigger-code list will be posted on the program website.
- Accountable vs. attributed providers: Grace (actuary) explained that an ‘attributed’ provider is the TIN with a trigger event; an ‘accountable’ provider is a TIN with historical attribution above a 30-case threshold and therefore eligible to receive a case rate rather than fee-for-service. Grace said, “Those providers will have a case-rate assigned to them versus the other providers even though they still can be the attributed provider.”
- Portability when members change providers: Charles said the case rate “will move with the member” as long as the receiving provider meets trigger and specialty criteria; in months when two qualifying providers bill, DSS has discussed paying both providers during that month and reconciling later to identify continuing care.
- Payment timing and scope: DSS said the case rate can begin in the second trimester and run through 90 days postpartum, covering professional fees (including vaginal and cesarean professional components). Facility claims (outpatient or inpatient facility charges) are excluded from the case rate and handled in target-price reconciliation.
- Data window for deriving case rates: Grace said case-rate derivation will be based on delivery dates from 03/01/2023 to 02/29/2024, with relevant prenatal and postpartum claims included.

DSS plans and next steps
DSS will publish a live Q&A document, an overview video, and technical materials. Richards and Tiffany offered one-on-one follow-ups for providers who believe draft case rates do not reflect their TIN’s experience. DSS also plans a cost dashboard during the performance year to show near-term trends (with a short lag) rather than real-time reporting.

The agency asked providers to continue sending detailed, case-level concerns to help actuaries identify anomalies. Richards closed by saying DSS recognizes the change is significant and that the program will need iterative refinement and continued provider engagement.