Through the Community Health Access and Rural Transformation (CHART) Model, CMS aims to continue addressing disparities by providing a way for rural communities to transform their health care delivery systems by leveraging innovative financial arrangements as well as operational and regulatory flexibilities.


The approximately 57 million Americans living in rural communities, including millions of Medicare and Medicaid beneficiaries, face unique challenges when seeking healthcare services, such as limited transportation options, shortages of health care services, and an inability to fully benefit from technological and care-delivery innovations. These challenges result in rural Americans facing worse health outcomes and higher rates of preventable diseases than those living in urban areas.

Model Details

CMS is providing funding for rural communities to build systems of care through a Community Transformation Track and is enabling providers to participate in value-based payment models where they are paid for quality and outcomes, instead of volume, through an Accountable Care Organizations (ACO) Transformation Track.

The Model aims to:

  • Increase financial stability for rural providers through the use of new ways of reimbursing providers that provide up-front investments and predictable, capitated payments that pay for quality and patient outcomes;
  • Remove regulatory burden by providing waivers that increase operational and regulatory flexibility for rural providers; and
  • Enhance beneficiaries’ access to health care services by ensuring rural providers remain financially sustainable for years to come and can offer additional services such as those that address social determinants of health including food and housing.

To achieve these goals, the CHART Model will test whether upfront investments, predictable capitated payments, and operational and regulatory flexibilities will enable rural health care providers to improve access to high quality care while reducing health care costs.

Community Transformation Track

In the fall of 2021, CMS awarded cooperative agreement funding to four entities under the CHART Community Transformation Track: University of Alabama Birmingham, State of South Dakota Department of Social Services, Texas Health and Human Services Commission, and Washington State Healthcare Authority. The awarded entities will serve as Lead Organizations in the respective states of Alabama, South Dakota, Texas, and Washington. The Lead Organizations in each of these states will use the award funds to develop and implement a health care redesign strategy for their defined community over the course of the model.

A Lead Organization is a single entity that represents a rural Community, comprised of either (a) a single county or census tract or (b) a set of contiguous or non-contiguous counties or census tracts. Each county or census tract must be classified as rural, as defined by the Federal Office of Rural Health Policy’s list of eligible counties and census tracts used for its grant programs. 

Lead Organizations will be responsible for working closely with key model participants (e.g., including Participant Hospitals and the state Medicaid agency) and driving health care delivery system redesign by leading the development and implementation of Transformation Plans with their community partners. The Transformation Plan is a detailed description that outlines the community’s plan to implement health care delivery redesign strategy.

Lead Organizations and their community partners will receive upfront cooperative agreement funding, financial flexibilities through a predictable capitated payment amount (CPA) for Participant Hospitals in a community, and operational and regulatory flexibilities.

The four Lead Organizations are critical to the success of the Model because they will coordinate efforts across the community to ensure that access to care is maintained and that the needs of various stakeholders are understood and accounted for in the transformation plan. Lead Organizations are responsible for managing cooperative agreement funding, recruiting Participant Hospitals, engaging the state Medicaid agency, establishing relationships with other aligned payers, convening the Advisory Council, and ensuring compliance with Model requirements. Ultimately, the Lead Organization will oversee the execution and coordination of a Transformation Plan that outlines the health care delivery redesign strategy for the Community.

ACO Transformation Track

Update: The ACO Transformation Track Request for Application (RFA) release date will now be spring 2022. CMS looks forward to sharing additional information when available.

CMS will select up to 20 rural-focused ACOs to receive advanced payments as part of joining the Medicare Shared Savings Program (Shared Savings Program). Building on the success of the ACO Investment Model (AIM), the advanced shared savings payments are expected to help CHART ACOs engage in value-based payment efforts that will improve outcomes and quality of care for rural beneficiaries. A majority of ACO providers/suppliers of the CHART ACO must be located within rural counties or census tracts as defined by FORHP.

CMS will offer CHART ACOs advanced shared savings payments comprised of two components:

  • A CHART ACO will be able to receive a one-time upfront payment equal to a minimum of $200,000 plus $36 per beneficiary to participate in the 5-year agreement period in the Shared Savings Program.
  • A CHART ACO will be able to receive a prospective per beneficiary per month (PBPM) payment equal to a minimum of $8 for up to 24 months.

The amount for the upfront payment and the PBPM will vary based on the level of risk that the CHART ACO accepts in the Shared Savings Program and the number of rural beneficiaries assigned to it based on the Shared Savings Program assignment methodology, up to a maximum of 10,000 beneficiaries.

The CHART ACO will enter into participation agreements with CMS to participate in both the Shared Savings Program and the CHART Model and, for the full duration of the agreement period, meet the requirement that a majority of its ACO providers and suppliers are located within rural counties or census tracts.



Community Transformation Track

CMS announced the Community Transformation Track Notice of Funding Opportunity (NOFO) in September 2020 and the application period closed on May 11, 2021. CMS anticipates announcing the selected Lead Organizations in fall 2021.

ACO Transformation Track

The Request for Application (RFA) for the ACO Transformation Track will be available in spring 2022.

Additional Information

Updates & Questions

If you are interested in receiving additional information and updates about the CHART, please subscribe to the CHART listserv.

If you have a question about the CHART Model, please email it to

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