[Federal Register Volume 69, Number 193 (Wednesday, October 6, 2004)]
[Notices]
[Pages 59929-59930]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-22459]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-5015-N]


Medicare Program; Care Management for High-Cost Beneficiaries 
(CMHCB) Demonstration

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Notice.

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SUMMARY: This notice informs eligible health care organizations of an 
opportunity to apply to implement and operate a care management 
demonstration serving high-cost beneficiaries in the original Medicare 
fee-for-service (FFS) program. This voluntary demonstration is part of 
an effort to develop and test multiple strategies to improve the 
coordination of Medicare services for high-cost FFS beneficiaries. The 
notice contains information on how to obtain the complete solicitation 
and supporting information.

DATES: Applications will be considered timely if we receive them on or 
before January 4, 2005.

ADDRESSES: Mail applications to--Centers for Medicare & Medicaid 
Services, Attention: Cynthia Mason, Mail Stop: C4-17-27, 7500 Security 
Boulevard, Baltimore, Maryland 21244.
    Because of staff and resource limitations, we cannot accept 
applications by facsimile (FAX) transmission or by e-mail.

FOR FURTHER INFORMATION CONTACT: Cynthia Mason at (410) 786-6680 or 
<a href="/cdn-cgi/l/email-protection#b2d1dfdad1d0d6d7dfddf2d1dfc19cdadac19cd5ddc4"><span class="__cf_email__" data-cfemail="71121c19121315141c1e31121c025f1919025f161e07">[email protected]</span></a>.

SUPPLEMENTARY INFORMATION:

I. Background

    The Department of Health and Human Services is developing and 
testing multiple strategies to improve the coordination of Medicare 
services for beneficiaries with high-cost conditions. However, one 
approach that remains to be studied is intensive management for high-
cost beneficiaries with various medical conditions to reduce cost as 
well as improve quality of care and quality of life for those 
beneficiaries. Therefore, we are interested in proposals to restructure 
care or enhance the management of care for beneficiaries with costly 
medical conditions. It is anticipated that organizations will serve 
high-risk beneficiaries with a variety of medical conditions and that 
the vast majority of beneficiaries participating in the demonstration 
will have multiple conditions. One organization will be selected per 
area to offer services to eligible beneficiaries. Beneficiary 
participation in the programs will be voluntary and will not change the 
amount, duration or scope of participants' fee-for-service (FFS) 
Medicare benefits. FFS Medicare benefits will continue to be covered, 
administered, and paid under the traditional Medicare FFS program. 
Programs will be offered at no charge to the beneficiary. Organizations 
chosen for the demonstration will not be able to restrict beneficiary 
access to care (for example, there can be no utilization review or 
gatekeeper function) or restrict beneficiaries to a limited number of 
physicians in a network.
    Applicants may propose to serve one or more areas, but their 
proposed service areas must be adjusted to ensure that the population 
is of an appropriate size that would ensure statistically significant 
results. Also, to avoid any overlap between the current FFS care 
management demonstrations or the Chronic Care Improvement Programs 
(CCIP), it will be necessary to exclude from the Care Management for 
High-Cost Beneficiaries (CMHCB) demonstration population any

[[Page 59930]]

beneficiaries who meet the criteria to participate in existing 
demonstrations or CCIP.
    Organizations may be paid a monthly fee per participant or 
participate under a gain-sharing arrangement based on Medicare savings; 
however, fee and gain-sharing payments will be contingent on 
improvements in clinical quality of care, beneficiary and provider 
satisfaction, and savings to Medicare in the intervention groups 
compared to control groups.

II. Provisions of This Notice

    This demonstration is intended to test models of care management 
for high-cost beneficiaries under the Medicare FFS program, 
incorporating relevant features from traditional disease management 
programs, but allowing sufficient flexibility for us and the awardees 
to adapt the design of CMHCB programs to meet the unique needs of the 
high-cost Medicare population. For some beneficiaries with high-cost 
conditions, the restructuring of the care management plan to integrate 
provider services in the program and to deliver those services in non-
acute care locations such as the beneficiary's home could significantly 
improve the beneficiary's quality of life while simultaneously reducing 
costs. Under the CMHCB demonstration, we hope to test a variety of 
models such as intensive case management, increased provider 
availability, structured chronic care programs, restructured physician 
practices, and expanded flexibility in care settings to deliver care to 
high-cost beneficiaries with multiple conditions.
    The organization(s) that are awarded the demonstration project will 
be required to agree to assume financial risk in the event of failure 
to meet agreed upon performance guarantees for clinical quality, 
beneficiary and provider satisfaction and savings targets. That 
financial risk will include all fees and gain-sharing payments.
    Organizations eligible to apply to implement and operate care 
management programs under CMHCB include--
    <bullet> Physician groups;
    <bullet> Hospitals; or
    <bullet> Integrated delivery systems.

    Other organizations may apply, but only as part of a consortium 
that includes physician groups, hospitals, or integrated delivery 
systems that would play a major role in the operation of the proposed 
CMHCB demonstration. Eligible organizations must be capable of 
providing ambulatory health care services.
    We plan to make approximately four to six awards. Interested 
parties can obtain complete solicitation and supporting information on 
the CMS Web site at http://www.cms.hhs.gov/researchers/demos/cmhcb.asp. 
Paper copies can be obtained by writing to Cynthia Mason at the address 
listed in the ADDRESSES section of this notice.

III. Collection of Information Requirements

    This information collection requirement is subject to the Paperwork 
Reduction Act of 1995 (PRA); however, the collection is currently 
approved under OMB control number 0938-0880 entitled ``Medicare 
Demonstration Waiver Application'' with a current expiration date of 7/
31/2006.

    Authority: Section 402(a)(1)(B) and (a)(2) of the Social 
Security Amendments of 1967, Pub. L. 90-248, as amended, 42 U.S.C. 
1395b-1(a)(1)(B) and (a)(2).

(Catalog of Federal Domestic Assistance No. 93.773 Medicare-Hospital 
Insurance Program; and No. 93.774, Medicare--Supplementary Medical 
Insurance Program)

    Dated: September 15, 2004.
Mark B. McClellan,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 04-22459 Filed 10-1-04; 4:00 pm]
BILLING CODE 4120-01-P


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