Medicare Care Choices Model: Archived Materials

**Disclaimer**: The materials on this page likely contain out-of-date information and are made available as a service to those who are looking for more background on this initiative.

Frequently Asked Questions

July 20, 2015

What is the Medicare Care Choices Model (MCCM) testing?

MCCM will test the impact on quality of care and patient and family satisfaction of allowing certain Medicare and dually eligible beneficiaries who qualify for coverage under the Medicare or Medicaid Hospice Benefit to receive palliative care services and curative care at the same time.  Currently, beneficiaries are required to forgo curative care in order to receive services under the Medicare or Medicaid hospice benefit.

 

How does MCCM operate?

The hospices will be paid a $400 per beneficiary per month (PBPM) fee for providing services under the model for 15 or more calendar days per month.  If services are provided under the model for fewer than 15 calendar days per month during the first month that the beneficiary is in the model, the hospices will be paid $200 PBPM.  As the beneficiary is not electing the Medicare hospice benefit, hospices participating in this model will not receive the Medicare Hospice Benefit per diem rates.

 

What are the requirements for a beneficiary to participate?

To participate in the MCCM, Medicare beneficiaries diagnosed with certain terminal illnesses (advanced cancers, chronic obstructive pulmonary disease, congestive heart failure, and human immunodeficiency virus/acquired immune deficiency syndrome) must meet hospice eligibility requirements under the Medicare or Medicaid Hospice Benefit; must not have elected the Medicare or Medicaid hospice benefit within the last 30 days prior to their participation in the
MCCM; and must have satisfied Model specific eligibility criteria.

 

Has CMS revised the design and scope of the model?

Yes. Due to the robust response received to the Request for Applications since the 2014 announcement of the model, the following changes to the model have been made:

  1. The MCCM has been expanded from 30 Medicare-certified hospices to about 140 Medicare-certified hospices of various sizes to target 150,000 eligible Medicare beneficiaries.
  2. The duration of the model was increased from 3 years to 5 years.
  3. The model will be phased in over 2 years. Participating hospices will be randomly assigned to Phase 1 or Phase 2.
  4. Hospices will receive payment under the model through the standard Medicare claims process.

 

When will hospices participating in the model’s first phase begin providing services to beneficiaries that elect to participate in the model? When will hospices in the second phase begin providing services under the model to beneficiaries that elect to participate in the model?

Phase 1 hospices will begin to deliver services under the model from January 1, 2016 to December 31, 2020.  Phase 2 hospices will begin to deliver services under the model 2 years later, from January 1, 2018 to December 31, 2020.

 

How will beneficiaries learn about this model?  Will they be required to participate?

Beneficiaries will learn about the model through the hospices and physician referral process.  They may elect to participate or refuse to participate in the model.

 

Will beneficiaries pay a copayment on the supportive services provided by hospices?

Services provided under the model are not subject to a co-pay.

 

How were the participating hospices selected for this model?

A Request for Application was published in the Federal Register in the spring of 2014 that invited hospices to apply to participate in the MCCM. Applications were reviewed and scored by an expert panel in hospice care and model implementation. Hospices that had the highest scores were recommended to be included in the model.

 

May 30, 2014

Can a networked group of hospices that are under State Action Immunity combine to apply for the Medicare Care Choices Model?

Yes. By law, or under State Action Immunity, none of these applicant hospices may compete for service. All agencies must serve everyone, regardless of where they live in the service area and regardless of payment source. Combined applicants must explain in their application their past experience working with other Medicare certified and enrolled hospices to provide coordinated care services with other providers in their service area. For these applicants, data must be shown separately by each applicant’s National Provider Identifier (NPI) number and then totaled across all of the applicants’ provider numbers. This combined application will be reviewed and determination for awards will be based on the merits of the group of applying hospices as a whole. Payment to hospices selected to participate in the Model will be made directly to the hospice utilizing its NPI number. Each hospice in the networked group remains responsible for its unique beneficiaries.

 

If a Medicare certified and enrolled hospice has exceeded the aggregate cap limit in the years specified in the Request for Applications and is currently in good standings with repaying monies back to Medicare, can that hospice apply for the Medicare Care Choices Model?

No. A hospice that has exceed their aggregate cap limit for the time period stated in the Request for Applications does not meet the qualifying criteria specified in the section Basic Requirements of Eligible Applicants. The applicant must demonstrate it is in good standing as demonstrated by not exceeding the inpatient hospice cap or the aggregate hospice cap for the cap years (11/1-10/31) 2012, 2011, and 2010 for which data are available.

 

Would the hospice agency be able to limit the number of beneficiaries they enroll in the Model?

Yes. The request for applications Model Design section requests information on the number of beneficiaries the applicant anticipates enrolling in the Model as well as an explanation of how the applicant arrived at this estimate.

 

Is review of the individualized care plan that includes the patient centered goals required every 15 days or every 30 days?

As per the Conditions of Participation at §418.56 (d) Standard: Review of the plan of care, the hospice interdisciplinary group (in collaboration with the individual's attending physician,) must review, revise and document the individualized care plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days.

 

Does the Model require a Hospice RN Case Manager (RNCM) to complete an in-person assessment for the purposes of updating the patient-centered goals and plan of care or, under this Model; is it acceptable to make updates based on telephone check-ins with the patient and patient’s team of healthcare providers?

The Conditions of Participation at §418.56 require the interdisciplinary group, as a whole, to update the comprehensive assessment at least every 15 days, and more frequently as the patient’s condition requires. While not explicit in the Conditions of Participation, the process to update the plan of care requires a face-to-face visit and assessment by the RN as the revised plan of care must include information from the patient's updated comprehensive assessment and must note the patient's progress toward outcomes and goals specified in the plan of care.

 

Is a RN case manager required for this Model, or could a hospice develop a model utilizing a Social Worker case manager?

The Conditions of Participation at §418.56 require that the hospice interdisciplinary group must designate a registered nurse, who is a member of that interdisciplinary group, to provide coordination of care and to ensure continuous assessment of each patient’s and family’s needs, and to ensure continuous implementation of the interdisciplinary plan of care. Whether the hospice chooses to add a social worker as a case manager, in addition to the required RN coordinator, is up to the Model participant.

 

Can a main hospice with multiple other hospices, each having their own National Provider Identifier (NPI), submit one application or must each hospice apply individually to participate in the Model?

Each hospice location participating in the Model must have an individual National Provider Identifier and must apply individually using its provider number. Each application will be reviewed and evaluated on the merits of that particular hospice. Payment to hospices selected to participate in the Model will be made directly to the hospice utilizing its provider number. CMS seeks to enroll geographically diverse hospices of differing sizes that serve demographically different populations.

 

The Request for Applications uses the term “traditional home”; does this include a group or boarding home?

Under the Medicare Care Choices Model, “home” is defined as a location or residence, other than a hospital or other facility, where the patient receives care in a residence. A beneficiary residing in a group home, defined as a residence, with shared living areas, where clients receive supervision and other services such as social and/or behavioral services, custodial service, and minimal services (e.g., medication administration), or a boarding home, defined as a home or facility (often a larger converted residence) where an individual rents a room and receives no supportive services would be eligible to participate. In order to be eligible for the Model, the qualifying beneficiary must have resided in a home, not an institutional setting for the purposes of receiving nursing or aide services, for a period of at least 30 days prior to their enrollment in the Model.

 

May 7, 2014

What is in-home respite and how is it different from inpatient respite?

In-home respite refers to the provision of short-term or temporary in-home care to allow the usual caregiver a brief break. In-home respite is typically provided by a volunteer or hospice staff (such as an aide to stay in the home with the beneficiary) and is intended to allow for lending relief for the caregiver. The use of volunteers and other support services, as appropriate, for this purpose is often a preferred method as it seems less clinical to the beneficiaries and families, and often relationships and trust are formed thus further promoting this service.

In-home respite care is similar to inpatient respite care, but is provided in the home.  When given to a hospice beneficiary, in-home respite is provided as part of routine home care, which Medicare pays for as part of the Medicare hospice benefit.  Inpatient respite care is paid under the Inpatient Respite level of care.  

 

Are beneficiaries that are enrolled in cardiac or pulmonary rehabilitation programs eligible for this Model?

Yes. Beneficiaries that participate in cardiac or pulmonary rehabilitation and meet the eligibility criteria for this model, as specified in the Request for Applications, are eligible to participate in this Model.

 

What are the criteria for hospital stays as it pertains to the Model?

In order to meet the criteria for the Model, the qualifying beneficiary must have two hospitalizations in the past 12 months. The inpatient hospital stay must be billed under Medicare Part A, and the Model qualifying diagnosis must be listed as one of the subsidiary diagnoses on the claim for that hospital stay.  An inpatient hospital stay does not include outpatient or observation stays.

 

What are the office visit requirements for a beneficiary to meet the qualifying criteria for this Model?

As indicated in the Request for Applications, Beneficiary Eligibility and Enrollment section, a qualifying beneficiary must have had at least three office visits related to the beneficiary’s qualifying diagnosis with the same Medicare enrolled healthcare provider (defined as primary care or specialist provider, such as oncologist, pulmonologist, cardiologist, etc.) within the last 12 months. The Model qualifying diagnosis must be listed as one of the subsidiary diagnoses on the claim for these visits. This healthcare provider is the referring provider to the Model and must certify that the Medicare beneficiary or Medicare-Medicaid enrollee meets the criteria for the Model. 

 

 Who is responsible for directing the care of the participating beneficiary in this Model?

In this Model, the beneficiary’s curative care provider is responsible for directing the care of the beneficiary. This Medicare provider is the one who referred the beneficiary to this Model. The hospice’s role in the Model differs significantly from the hospice’s role in the Medicare hospice benefit. The role of the hospice in this Model is to provide supportive care and to integrate care with the beneficiary’s curative providers by providing case management, care coordination, shared decision making, and other services listed in Table 1 of the Request for Applications.

 

What is the role of the beneficiary’s curative care provider or referring healthcare provider in this Model?

The Medicare enrolled curative care provider or referring health care provider is the provider who has provided at least three office visits in the last 12 months related to the Model’s qualifying diagnosis. This referring health care provider remains the beneficiary’s provider responsible for directing the care of the participating beneficiary in this Model. While the hospice is responsible for educating the beneficiary about the Model, the referring health care provider is responsible for attesting that the beneficiary meets the Model eligibility criteria listed in the Beneficiary Eligibility and Enrollment section. The Model participating hospice and the curative care providers and suppliers must work together through the hospice nurse care coordinator to provide case management and to provide input into the interdisciplinary group meetings and development of the Model beneficiary’s plan of care.

 

If a beneficiary passes away while enrolled in the Model, is the participating hospice expected to offer bereavement services to the family?

Yes. Participating hospices are expected to provide bereavement services in the event that the beneficiary passes away while enrolled in the Model. Bereavement services, defined as emotional, psychosocial, and spiritual support and services provided before and after the death of the patient to assist with issues related to grief, loss, and adjustment are listed within Table 1 of the Request for Applications and must be consistent with the hospice Conditions of Participation at §418.204. These services are expected to be available to the families of beneficiaries’ who have participated in the Model. 

 

If the beneficiary is hospice eligible when entering the Model and subsequently is no longer hospice eligible, is the beneficiary still eligible to remain in the Model?

Yes. There is no recertification period in the Model. The referring health care provider, who is the beneficiary’s provider for the three qualifying office visits, is responsible for attesting that the beneficiary meets the Model eligibility criteria listed in the Beneficiary Eligibility and Enrollment section.

Once the beneficiary consents in writing to the Model, the beneficiary may stay in the Model regardless of whether the beneficiary’s health improves. CMS recognizes that the illness trajectory of beneficiaries enrolled in the Model may not be linear. The availability of supportive care provided by the hospice during all phases of the terminal illness will provide valuable data on the amount and kinds of services utilized by Model beneficiaries. This eligibility to remain in the Model is a significant distinction from the Medicare hospice benefit.

 

 Is there a recertification period?

No. There is no recertification period in the Model. Unlike the Medicare hospice benefit, the Model does not have an election period. Once a hospice eligible beneficiary, who meets the criteria for the Model consents to participate in the Model, the beneficiary may remain in the Model without recertification of eligibility. However, CMS will closely track enrollment in this Model to ensure that only appropriate beneficiaries are enrolled.

 

How long will the Medicare Care Choices Model last?  Must a hospice participate the entire time?

The Medicare Care Choices Model will last three years. Participation is voluntary, but it is expected that Medicare certified and enrolled hospices will enroll at the beginning of the model and commit to participating for the full three years.

 

If the dollar value of the services listed under Table 1 of the Request for Applications that hospice may provide to a Model beneficiary exceed the $400 per beneficiary per month fee, would that be construed as an inducement?

No. Since the covered services the hospice is to provide are bundled, inducement is not an issue. In a given month the hospice may provide more services than the $400 per beneficiary per month fee paid for the bundle to a beneficiary and at other times the hospice may provide fewer services than the fee paid for the bundle to a beneficiary. There is an expectation that some beneficiaries need more and others less services based on their plan of care.  

 

April 21, 2014

Is the beneficiary e nrolled in the Medicare hospice benefit in order to participate in the Model?

No. The Request for Application states, in the “Beneficiary Eligibility and Enrollment” section, that a beneficiary who is enrolled in the Medicare hospice benefit is not eligible to participate in the Model. Beneficiaries eligible to participate in this Model must be hospice-eligible, but not have elected the Medicare hospice benefit within the last 30 days prior to their participation in the Model.

 

Do hospices have to implement the Medicare Care Choices Model to include all hospice-eligible, terminal illnesses being tested (congestive heart failure, chronic obstructive pulmonary disease, cancer, or HIV/AIDS) or can a hospice applicant focus on a specific population amongst the terminal illnesses being tested?

Applicants may implement the Model utilizing any single, multiple or all of the Model qualifying diagnoses. The application must provide an explanation as to why a particular population is selected by the applicant and how this decision will improve the quality of care being delivered and/or satisfaction of the beneficiary receiving Model services.

 

Can beneficiaries who are homebound participate in the Medicare Care Choices Model?

Yes. The Model does not exclude beneficiaries who are homebound and meet the Model eligibility criteria.

 

The Request for Applications states, “…the applicant must be able to demonstrate experience providing care coordination services and/or case management as well as shared decision-making to beneficiaries prior to electing the Medicare hospice benefit (MHB) in conjunction with their referring providers/suppliers.” If the applicant does not have contact with the beneficiary before they enter hospice, how can this requirement be demonstrated?

While some hospices may have the ability, through palliative care programs, to provide care coordination services and/or case management as well as shared decision-making to beneficiaries prior to electing the Medicare hospice benefit, other hospices can provide information to demonstrate how they have provided these services within their existing programs. CMS seeks information on any and all examples of shared decision-making, incorporation of patient-centered goals and case management or care coordination.

 

Can a “reduced” or “modified” version of the Model be put in place?

No. All services, as listed in Table 1 of the Request for Applications, must be available to every Model beneficiary. The actual services provided are based on the patient’s centered goals and plan of care. Hospice Conditions of Participation are in full effect under this Model.

 

The Request for Applications states that “CMS does not expect to see claims in the Medicare or Medicaid systems for home health services.” Can beneficiaries who are participating in the Medicare Care Choices Model receive intermittent skilled nursing services, billed outside of the $400 per beneficiary per month fee, from a home healthcare agency?

Yes, intermittent skilled nursing services can be provided and billed outside of the $400 per beneficiary per month fee; however, typically nursing services are to be provided by the hospice as part of the bundled fee. To participate in the Model and receive home healthcare services, a beneficiary must meet the criteria for home healthcare benefits under 42 CFR § 409.42.

Participating hospices must provide documentation in the beneficiary’s medical record and Plan of Care that clearly delineates why these services were provided by the home health agency and not the participating hospice. Additionally, the hospice must provide documentation in the Service and Activity log that clearly demonstrates what services the hospice provided during this episode of home health care that are different from the services provided by the home health agency.

 

What does the $400 per beneficiary per month fee cover?

As listed in Table 1 of the Request for Applications, the $400 per beneficiary per month fee covers the services listed below. The number and frequency of the services provided is based on the beneficiary’s patient-centered goals and the Plan of Care. Hospice Conditions of Participation are in full effect under this Model.

  • Counseling services to beneficiary and family
    • Bereavement
    • Spiritual
    • Dietary
  • Family support
  • Psycho-social assessment
  • Nursing services
  • Medical social services
  • Hospice aide and homemaker services
  • Volunteer services
  • Comprehensive assessment
  • Plan of care
  • Interdisciplinary Group (IDG)
  • Care coordination/case management services
  • In-home respite care

 

Can conveners apply to the Medicare Care Choices Model?

No. Conveners do not meet the eligibility criteria as stated in the Medicare Care Choices Model Request for Applications:

“Providers eligible to apply for participation in this Model are Medicare certified and enrolled hospice programs in good standing and of all sizes located in a mix of rural and urban areas that are already experienced in care coordination, and/or case management with a network of various types of healthcare providers as well as shared decision making with patients and families.”

 

Is there a maximum or minimum number of beneficiaries each hospice is required to enroll in the Medicare Care Choices Model?

No. The Request for Applications does not specify a required number of beneficiaries each hospice must enroll. The application should include the number of beneficiaries that are expected to be enrolled in the three-year Model and broken down by each year of the Model.

 

April 04, 2014

Some beneficiaries are already receiving services listed in Table 1, of the Medicare Care Choices Model Request for Applications. These services are currently being billed under Medicare Parts A, B, and D. Is the $400 per beneficiary per month meant to replace existing billing for services already being provided?

No. If a service listed in Table 1 of the Medicare Care Choices Model Request for Applications) is currently being delivered to a beneficiary using an acceptable billing code under Part A, B, or D, the service may continue to be billed in that way. The $400 per beneficiary per month is intended to allow for the provision of services that are not billable under Parts A, B, and D. CMS expects applicants to clearly describe how they will utilize the $400 per beneficiary per month to improve quality of care.

 

Is the $400 per beneficiary per month intended to replace the per diem rate for the Medicare hospice benefit?

No. The beneficiaries eligible to participate in this Model are hospice eligible, but have not elected the Medicare hospice benefit, and therefore are not eligible for the per diem payment under the Medicare hospice benefit. At any point during the course of participation in the Model, a beneficiary may choose to leave the model for any reason. If the beneficiary seeks only hospice care under the Medicare hospice benefit, a hospice Notice of Election would be signed and the beneficiary would no longer participate in the Model. At that time, a hospice would receive the per diem rate for all services covered by the hospice benefit and no longer receive the $400 per beneficiary per month.

 

Do we need to have an established palliative care program in place to apply for the Medicare Care Choices Model?

No, an established palliative care or case management program is not a requirement for application.

 

Once the beneficiary chooses this Model, at a later date can he/she choose to revoke from this Model and elect the Medicare hospice benefit?

Yes. If the beneficiary seeks only hospice care under the Medicare hospice benefit, the beneficiary would revoke from the Model.  The beneficiary would sign a hospice Notice of Election and the beneficiary would be enrolled in the Medicare hospice benefit.  At that time, the beneficiary would no longer participate in the Model.

 

Once a beneficiary chooses this Model, does he/she have to stay in this Model until the end of his/her life?

No. At any point during the course of participation in the Model, a beneficiary may choose to leave the Model for any reason. Once the beneficiary leaves the Model, he/she would not be eligible to return to the Model at a later date.

 

Can beneficiaries who are assigned to Accountable Care Organizations participate in this model?

Yes. The $400 per beneficiary per month fee will be taken into account during the calculation of shared savings to ensure that beneficiary-level expenditures are accurately reflected in final shared savings payments.

 

Is there an application form available for the Medicare Care Choices Model?

No. The Request for Application is the document that provides the information for writing your application. Table 2, “Application Criteria and Checklist,” lists the necessary elements required in the application. The Request for Application is a PDF file located in the “Additional Information” section of the Medicare Care Choices Model web page.

 

The Application Checklist requests length of stay data for the past 3 federal fiscal years. We are a new hospice, and do not have three years of data. Can we apply for the Medicare Care Choices Model?

Yes, your hospice agency would be able to apply for participation in the Model. The selection criteria will award points based on the applicant’s qualifications and demonstrated results in meeting these requirements.

 

Is a Letter of Intent required?

No. Application to the Medicare Care Choices Model does not include a Letter of Intent.

 

Are there any webinars, conference calls or Q&A sessions scheduled for this RFA?

Yes, there is a scheduled webinar for April 9, 2014 and an Open Door Forum will be scheduled for April 16, 2014. Additional information can be found on the Medicare Care Choices Model web page.

 

Is there a listserv for the Medicare Care Choices Model?

Yes, you can subscribe for the listserv through this link.

 

If I have questions or comments about the Request for Application where can I direct them?

Please check the FAQs for the most recent updates and information. Questions can also be sent to the Medicare Care Choices Model mailbox CareChoices@cms.hhs.gov.

 

March 18, 2014

What are the requirements for a beneficiary to participate?

To participate in the Medicare Care Choices Model and receive services from a participating hospice, beneficiaries with advanced cancers, chronic obstructive pulmonary disease, congestive heart failure and HIV/AIDS must meet Medicare hospice eligibility requirements under the Medicare hospice benefit, must not have elected the Medicare hospice benefit within the last 30 days prior to their participation in the Medicare Care Choices Model, and must have satisfied all of the eligibility criteria listed in the Beneficiary Eligibility and Enrollment Section of the Request for Applications.

 

What authority does CMS have to release this solicitation?

Section 1115A of the Social Security Act authorizes the Center for Medicare and Medicaid Innovation to test innovative payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care furnished to Medicare, Medicaid, and Children’s Health Insurance Program beneficiaries.

 

How does a hospice provider submit an application?

Applications must be mailed or hand delivered by the specified due date to the following address:

Centers for Medicare & Medicaid Services
Center for Medicare and Medicaid Innovation
Mail Stop WB-06-05
Attention: Cindy Massuda
7500 Security Blvd
Baltimore, Maryland 21244-1850

Please note we will not accept applications by any other means such as facsimile (FAX) transmission or by email. Applications received after June 19, 2014 will not be considered. Applicants must submit their application in a manner that provides proof of timely delivery of their application, such as FedEx or UPS. It is the applicant’s responsibility to be able to prove delivery of the complete application by the due date.

 

How will applications be reviewed and sites chosen?

The review of applications will be comprised of an evaluation and scoring by an internal review panel based on the requirements outlined in the Request for Applications. The outcome of this review will be submitted to the CMS approving official for a final decision.

 

What providers are eligible to apply to this model?

The applicant must be a Medicare certified and enrolled hospice based on its Medicare provider number. CMS seeks a diverse group of hospices representative of various geographic areas, both urban and rural, and hospices of varying sizes. Further, the applicant must be able to demonstrate experience providing care coordination services and/or case management as well as shared decision-making to beneficiaries prior to electing the Medicare or Medicaid Hospice Benefit in conjunction with their referring providers/suppliers.

 

When are applications due? How long is the application period open?

Applications are due no later than June 19, 2014. The application period is open for 90 days from date of publication in the Federal Register.

Additional Information