Actuarial Studies: CMMI Model Certifications

Section 1115A of the Social Security Act established the Center for Medicare and Medicaid Innovation (CMMI) within the Centers for Medicare & Medicaid Services (CMS) to test innovative payment techniques and service delivery models. For successful models, the law states that “the Secretary may, through rulemaking, expand (including implementation on a nationwide basis) the duration and the scope of a model that is being tested…to the extent determined appropriate by the Secretary, if—

1. The Secretary determines that such expansion is expected to—
   (A) reduce spending under the applicable title without reducing the quality of care; or
   (B) improve the quality of patient care without increasing spending;
2. The Chief Actuary of the Centers for Medicare & Medicaid Services certifies that  such expansion would reduce (or would not result in any increase in) net program spending under the applicable titles; and
3. The Secretary determines that such expansion would not deny or limit the coverage or provision of benefits under the applicable title for applicable individuals.”

The following certifications for potential model expansions have been prepared.

• Certification of Home Health Value-Based Purchasing
• Certification of the Medicare Prior Authorization Model for Repetitive Scheduled Non-Emergent Ambulance Transport
• Medicare Diabetes Prevention Program
• Pioneer Accountable Care Organization (ACO) Model

See downloads below.