Medicare Care Choices Model - Frequently Asked Questions

This page was last updated on April 9, 2018

Table of Contents


MCCM Background

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

The MCCM is testing the impact on quality of care and patient and family satisfaction of allowing certain Medicare and dually eligible beneficiaries to receive supportive services provided by participating hospices while concurrently receiving services from their other Medicare providers, including treatment for the terminal condition. Currently, beneficiaries are required to forgo Medicare payment for treatment for the terminal condition in order to receive services under the Medicare or Medicaid hospice benefit.

 

How does the MCCM operate?

The participating hospices are paid a per beneficiary per month (PBPM) fee for providing select hospice services to beneficiaries participating in the MCCM.

In a beneficiary's first month of model enrollment, the hospice is paid $200 for beneficiaries who are enrolled in the model for less than 15 calendar days, and $400 for beneficiaries who are enrolled in the model for 15 or more calendar days. Hospices receive $400 per beneficiary for each subsequent month of enrollment when a MCCM claim is submitted, including $400 in the month of discharge, regardless of the number of days of enrollment. 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 for beneficiaries enrolled in the model.

The duration of the model is 5 years, and participating hospices were randomly assigned to Cohort 1 or Cohort 2. Cohort 1 hospices began beneficiary enrollment in the model on January 1, 2016, and Cohort 2 hospices began beneficiary enrollment in the model on January 1, 2018. The model will run through December 31, 2020. Hospices receive payment for model services through the standard Medicare claims process.

 

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.

 

Does a beneficiary need to be enrolled in the Medicare hospice benefit in order to participate in the model?

No. Beneficiaries eligible to participate in this model must be hospice-eligible, but not have elected the Medicare or Medicaid hospice benefit within the 30 days prior to model enrollment.

 

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)?

Applicants may implement the model utilizing any one or more of the model qualifying diagnoses.

 

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

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

 

What authority does CMS have to test this model?

Under Section 1115A of the Social Security Act (as added by section 3021 of the Patient Protection and Affordable Care Act), the Center for Medicare and Medicaid Innovation is authorized to test innovative payment and service delivery models to reduce Medicare, Medicaid or Children’s Health Insurance Program (CHIP) expenditures while maintaining or improving the quality of care for Medicare beneficiaries.

 

What types of providers are eligible to participate in the model?

MCCM participating providers must be Medicare certified hospices. Participating hospices represent various geographic areas, both urban and rural, and are of varying sizes and business models.

 

MCCM Eligibility

What are the requirements for a beneficiary to participate?

To participate in the MCCM, beneficiaries must:

  • Be diagnosed with at least one of the following terminal conditions: advanced cancer, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), or human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS);
  • Have traditional Medicare Parts A and B as primary health insurance for the 12 months prior to model enrollment;

  • Live in a traditional home (not an institutional setting) continuously for 30 days prior to model enrollment, unless an exception applies;*

  • Have had at least one hospital encounter (inpatient admission, ED visit, or observation stay) within the 12 months prior to model enrollment;

  • Have had three office visits for any reason with any Medicare participating provider within the 12 months prior to model enrollment;

  • Be certified by the community provider of six months prognosis with a Certificate of Terminal Illness, and co-signed by hospice medical director or hospice physician participating on the interdisciplinary team;

  • Reside within the service area of the participating hospice.

* Beneficiaries with stays in SNFs or inpatient rehabilitation facilities, that is not their permanent residence, can be enrolled into the model after discharge without waiting 30 days

 

What changes has CMS made to the eligibility criteria since the model began?

Due to model experience and feedback from model participants and industry stakeholders, some MCCM eligibility criteria have been changed since model initiation. In April of 2016, the requirement of a model beneficiary to have a Part D standalone plan was removed. Also in April of 2016, the MCCM hospital requirement was changed from two inpatient admissions in the last 12 months related to the terminal diagnosis to the current requirement of one hospital encounter (ED visit, observation stay or inpatient admission) in the last 12 months for any reason. In January of 2017, the MCCM insurance requirement was changed from a model beneficiary needing to have Medicare Part A for 24 months prior to model enrollment and Medicare Part B at time of enrollment, to the current requirement of model beneficiaries having both Medicare Part A and Part B for 12 months prior to model enrollment. Also in January of 2017, the MCCM office visit criteria was changed from 3 office visits in the 12 months prior to model enrollment with the beneficiary's primary care or specialist provider for a reason related to the terminal condition to 3 office visits in the 12 months prior to model enrollment with any Medicare provider for any reason.

 

What does it mean that a patient has to live in a traditional home at the time of enrollment?

The ‘traditional home setting’ is a private home where there are no assistive services included (assistive services in the beneficiaries' private home are allowed). In the MCCM, ‘the traditional home setting’ does not include skilled nursing facilities (SNFs), inpatient rehabilitation facilities or assisted living. Beneficiaries with stays in SNFs or inpatient rehabilitation facilities, that is not their permanent residence, can be enrolled into the model after discharge without waiting 30 days.

 

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

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

 

Can a beneficiary dis-enroll from the MCCM?

Yes. The beneficiary can choose to withdraw from the MCCM at any time and for any reason. However, once a patient dis-enrolls from the MCCM, they cannot re-enroll at a later date.

If the beneficiary wishes to elect the Medicare hospice benefit, they would first dis-enroll from the MCCM. When electing the Medicare hospice benefit, all regular procedures, including a hospice Certification of Terminal Illness (CTI) and a Notice of Election (NOE) submission, would apply.

 

Model Operations

What services will the hospice offer the MCCM-enrolled beneficiary?

Participating hospices will offer the below services to MCCM enrolled beneficiaries. The number and frequency of the services provided is based on the beneficiary’s patient-centered goals and the individualized plan of care. All services must be available to every model beneficiary.

  • Counseling services to beneficiary and family, including:
    • 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

 

Who is responsible for directing the care of the model participating beneficiary?

The beneficiary identifies a primary Medicare enrolled, non-hospice, community-based practitioner, (MD, DO or NP) to lead their care on the MCCM. This practitioner provides care to the patient in collaboration with the MCCM hospice with the goal of achieving better patient-centered outcomes and supporting shared decision making. This individual can be, but is not necessarily, the same non-hospice physician who signs the Certificate of Terminal Illness (CTI). The role of the hospice in this model is to provide supportive care and to integrate care with the beneficiary’s other medical providers by providing case management, care coordination, shared decision making, and other services listed in Table 1 of the Request for Applications.

 

How often does the MCCM plan of care need to be revised?

The plan of care must be reviewed and, if needed, revised by the interdisciplinary group (IDG) as the patient's needs change or every 15 calendar days, whichever comes first. In the MCCM, follow up assessments can be completed telephonically or in person, depending on the patient's needs and plan of care. The hospice MCCM RN Care Coordinator assures that all appropriate disciplines have contributed, including the patient or family, to the comprehensive assessment and it is complete.

 

Is a RN case manager required for this model?

The Conditions of Participation §418.56 applies here, which requires that the hospice interdisciplinary group must designate a registered nurse (RN), 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.

 

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

In-home respite refers to the provision of brief support (usually hours and not overnight) in the home, often by a volunteer or hospice staff member. In-home respite allows the unpaid caregiver (usually a family member or a friend) a break from caregiving responsibilities. The MCCM offers in-home respite but does not offer inpatient respite (overnight stays in a hospice facility or hospital), as does the Medicare hospice benefit.

 

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. MCCM hospices should follow their own policies and procedures that are aligned with state and local laws when responding to a patient who is near death or has died. The patient's end-of-life wishes should be known and honored. The MCCM hospice team is expected to provide support to the family, including social work, bereavement, counseling, etc., as they would at the time of death of hospice patients.

 

Does the MCCM have recertification periods?

No. There are no recertification periods in the MCCM. Unlike the Medicare hospice benefit, the model does not have an election period. Once a model eligible beneficiary enrolls in the MCCM, the beneficiary may remain in the model without recertification of eligibility.

 

Does the model beneficiary need to be discharged (dis-enrolled) from the MCCM if they are no longer believed to have only six months to live?

MCCM enrollees do not have to be discharged if their health improves and they are no longer believed to have only six months to live. The MCCM does not have a recertification requirement, unlike the Medicare hospice benefit. The model benefits from understanding the impact of supportive care services provided by participating hospices during all phases of terminal illness, including periods of improved health status.

 

Can a MCCM beneficiary receive services from a home health agency (HHA) while enrolled in the model?

Home health (HH) is an enduring benefit of Medicare for beneficiaries, including those participating in the MCCM; MCCM patients remain eligible for Medicare home health services, which can be provided and billed outside of the $400 per beneficiary per month fee. Where the patient’s needs extend beyond the usual hospice interventions, the patient-identified community practitioner's judgment and the patient’s best interests and preferences are paramount. If HH services are needed, it must be initiated by a non-hospice practitioner. In cases where the plan of care includes HH, the MCCM participating hospice should continue to fulfill its obligations under the MCCM to provide in-home support services including nursing and aide services. In addition, 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 HH agency and not the participating hospice. Additionally, the hospice must provide documentation in the Service and Activity log that clearly demonstrates what HH services the hospice provided during this episode that are different from the services provided by the HH agency. A 20 percent random sample of records where the MCCM and HH services are used concurrently will be reviewed by The Medicare Administrative Contractor (MAC). This is in addition to the 5 percent random sample of all MCCM records that will be reviewed by the MAC.  

 

MCCM Contact Information

Where can I direct questions or comments about the model?

Questions can be sent to the Medicare Care Choices Model mailbox at CareChoices@cms.hhs.gov.