August 11, 2020

On Tuesday, August 11, the Centers for Medicare & Medicaid Services Innovation Center announced the Community Health Access and Rural Transformation (CHART) Model to address disparities in healthcare services in rural communities. The CHART model is a result of President Trump’s Executive Order last week on Improving Rural Health and Telehealth Access and CMS’s Rethinking Rural Health Initiative. CMS also released an accompanying Model Fact Sheet. The Model aims to:

• Increase financial stability for rural providers through new methods of reimbursement;
• Remove the regulatory burden on rural providers and increase flexibility through waivers; and
• Ensure rural providers remain financially sustainable and allow them to offer additional services to address social determinants of health including food and housing.

Community Transformation Track

Through the Community Transformation Track, CMS will provide funding to 15 rural communities to build systems of care. These communities will be represented by a Lead Organization such as a state Medicaid agency, State Office of Rural Health, local public health department, Independent Practice Association, or Academic Medical Center. The rural community will be comprised of either a single or a set of county or census tracts defined as rural by the Federal Office of Rural Health Policy (FORHP). Lead Organizations will work with model participants such as participant hospitals and the state Medicaid agency to drive the health care system redesign.

The Lead Organization and their community partners will receive:

• Upfront funding in the form of cooperative agreements of up to $5 million, with up to $2 million available upon acceptance and the rest available as the community progresses through the model;
• Financial flexibilities providing participant hospitals a stable revenue stream creating incentives to reduce fixed costs and avoidable utilization;
• Operational and regulatory flexibilities including Medicare waivers to waive cost sharing for Part B services, provide beneficiaries with transportation, and offer rewards and incentives for Chronic Disease Management Programs. Benefit Enhancements include:
  • Waiver of requirement for a 3-day inpatient stay prior to admission to a Skilled Nursing Facility (SNF);
  • Telehealth Expansion (continued post-COVID-19);
  • Post-Discharge Home Visits;
  • Care Management Home Visits;
  • Critical Access Hospital (CAH) 96 Hour Rule; and
  • Waiver of Medicare hospital conditions of participation to allow a rural outpatient department and emergency room to be paid as if they were classified as a hospital.

Requirements for community partner participation in the Community Transformation Track includes:

• Participant hospitals must be acute care hospitals, Critical Access Hospitals (CAHs), or have a special rural designation;
• The state Medicaid agency must partner and be a sub-recipient of cooperative agreement funding to ensure Medicaid alignment with the CPA through Medicaid Fee for Service, Medicaid managed care plans, or both; and
• Lead Organizations must convene an Advisory Council to advise on activities conducted through the Model.

Accountable Care Organization (ACO) Transformation Track

Through the Accountable Care Organization (ACO) Transformation Track, CMS will select up to 20 rural-focused ACOs to receive advanced payments as part of joining the Medicare Shared Savings Program, building on the ACO Investment model (AIM), to allow ACOs to engage in value-based payment arrangements. A majority of ACO providers/suppliers must be located within rural counties or census tracts as defined by FORHP.

There will be two components to the advanced shared saving program for CHART ACOs:

1. A one-time upfront payment of $200,000 (minimum) plus $36 per beneficiary to participate in the 5-year agreement period; and
2. A prospective per beneficiary per month (PBPM) payment equal to $8 (minimum) for up to 24 months.

These payment amounts will vary based on

the level of risk that a CHART ACO accepts and the number of rural beneficiaries assigned to it based on the Shared Savings Program assignment methodology (with a maximum of 10,000 beneficiaries).

CHART ACOs can also use the benefit enhancements available in the Medicare Shared Saving Program including the waiver requirement for a 3-day inpatient stay prior to admission to a Skilled Nursing Facility (SNF) and the Beneficiary Incentive Program.

Timeline

• September: CMS anticipates the Notice of Funding Opportunity (NOFO) for the Community Transformation Track will be available on the Model website
• Early 2021: The Request for Application (RFA) for the ACO Transformation Track will be made available