AHEAD Model Frequently Asked Questions

• General All-Payer Health Equity Approaches and Development (AHEAD) Model Details FAQs
• Hospital Participation in the AHEAD Model FAQs
• CMS-Designated Medicare FFS Hospital Global Budget FAQs
• Primary Care Participation in the AHEAD Model FAQs
   

General All-Payer Health Equity Approaches and Development (AHEAD) Model Details

1. When will the application be available, and who is eligible to apply?

   CMS released a Notice of Funding Opportunity (NOFO) for the AHEAD Model on November 16, 2023, and will offer two application periods. 

   • CMS will accept applications for Cohort 1 and 2 through March 18, 2024.
   • Applications for Cohort 3 may be submitted through August 12, 2024.

   The first NOFO application period opened on November 16, 2023. Prospective applicants for Cohorts 1 and 2 have 120 calendar days to submit applications. CMS anticipates announcing awardees for Cohorts 1 and 2 in May 2024.

   The second NOFO application period opens on June 12, 2024. Prospective Cohort 3 applicants will have 60 calendar days to submit applications. The application for Cohort 3 is identical to the application for Cohorts 1 and 2, and applicants for Cohort 3 may begin preparing their application before the second NOFO application period opens. CMS anticipates announcing Cohort 3 awardees in mid-October 2024.

   Applicants interested in applying to participate in AHEAD must meet the following requirements:

   • Be a state agency (e.g., state Medicaid agency, state health department, state public health agency, state insurance agency, or other state entity with rate-setting or budget authority) operating in one of the 50 states, Washington, D.C., or a U.S. territory.
   • Apply as a single state agency or through a joint application on behalf of several agencies within a single state. If state agencies submit a joint application, only one agency can serve as the award recipient on behalf of their state and must be able to accept Cooperative Agreement funding. A state’s Medicaid agency must be involved in the application process. If the state Medicaid agency does not serve as the lead state applicant, they must be consulted and listed as a “subrecipient” on the application.
   • Have at least 10,000 Medicare fee-for-service (FFS) beneficiaries enrolled in Medicare Parts A and B residing in the state or selected sub-state region.

   Please note that states and sub-state regions in which the Making Care Primary (MCP) Model will be implemented are not eligible to participate in AHEAD. If MCP is operating in a sub-state region within a state, a different sub-state region with no geographic overlap in that state would be eligible to participate in AHEAD. If MCP will be implemented on a state-wide basis in a state, the entire state is not eligible to participate in AHEAD.

    

2. Can multiple sub-state regions within one state or territory participate in the AHEAD Model?

   If a state elects to participate in the AHEAD Model via a sub-state region rather than on a statewide basis, and that sub-state region meets the eligibility criteria listed in the NOFO, it may participate in the AHEAD Model through a single sub-state region.

   A sub-state region is defined as a group or groups of zip codes within a state that do not encompass an entire state and may or may not be close in location (i.e., do not need to share a common border). If a state elects and is accepted to participate in the AHEAD Model via a sub-state region, the state’s performance will be assessed based on its participation at the sub-state region level. States may not apply to participate in the AHEAD Model through multiple, separate sub-state regions.

    

3. 3. How are states selected to participate in the AHEAD Model?

   States interested in participating in the AHEAD Model must apply during the NOFO period. This will be a competitive application process, including a merit review of all applications. The merit review panel will score applications using a detailed rubric, which is available to all applicants as part of the NOFO.

   Interested states can submit an optional, non-binding Letter of Intent (LOI) to express their interest in applying. Letters of Intent are due at least 45 calendar days before NOFO applications are due (i.e., February 5, 2024, for Cohorts 1 and 2, and July 26, 2024, for Cohort 3). Potential applicants considering Cohort 3 may submit their LOI any time before the July 26, 2024, deadline, including submission by the Cohort 1 and 2 deadlines on February 5, 2024. 

    

4. What information will applicants be required to provide in their application?

   States interested in submitting a NOFO application should be prepared to provide the following information:

   • A description of the state applicant and any partners.
   • An assessment of readiness to implement AHEAD Model components, which include factors such as: existing legislation related to primary care investment and/or cost growth; a vision for population health improvement and primary care transformation; proposed strategy for hospital and primary care provider recruitment; proposed strategy for Medicaid and multi-payer alignment; and description of current population health and health equity activities.
   • A detailed budget, including a budget narrative. 
   • State applicants interested in implementing the AHEAD Model within a sub-state region must provide rationale for this request.

   The merit review and selection process will be outlined in the NOFO. CMS will consider the geographic diversity and scale of all applications when making final award determinations. CMS will select up to eight recipients at CMS’ sole discretion. 

    

5. How can Cooperative Agreement funding be used?

   Applicants selected to participate in the model will receive up to $12 million in Cooperative Agreement funding.

   Specific parameters around how these funds can be used are included in the NOFO. Generally, funding is intended to support model planning and implementation activities, including but not limited to: 

   • Recruiting primary care providers and hospitals to participate in the model 
   • Setting statewide total cost of care (TCOC) cost growth targets and primary care investment targets
   • Building behavioral health infrastructure and capacity
   • Supporting Medicaid and commercial payer alignment
   • Hiring new staff to support the model
   • Investing in new technology
   • Supporting demographic data collection

   • Developing Medicaid hospital global budget methodology

      

6. Can AHEAD be implemented in both Medicaid Managed Care and Fee-For-Service contexts?

   Yes. The AHEAD Model can be implemented both for managed care and fee-for-service (FFS) populations in Medicaid. CMS’ Innovation Center and Center for Medicaid and CHIP Services (CMCS) have collaborated closely to ensure that Medicaid hospital global budgets, Patient-Centered Medical Home (PCMH) or other Medicaid primary care Alternative Payment Model (APM) participation, and other Medicaid components of the model can be successful across varying state health care delivery systems and administrative contexts. In managed care contexts, Managed Care Organizations (MCOs) will be a key partner and stakeholder in the development of Medicaid hospital global budget methodology and the administration of global budget payments in participating states. Similarly, in participating states, state Medicaid Agencies will work with CMCS to obtain the necessary authorities for Medicaid alignment in AHEAD, whether for FFS or managed care. Please see the AHEAD Notice of Funding Opportunity, particularly the Medicaid Alignment Criteria in Appendix VIII, for more information on AHEAD Medicaid alignment and considerations for managed care and FFS.

    

7. What data collection and data sharing requirements are included in the model?

   The AHEAD Model requires participating states to collect and report statewide quality, health equity, and all-payer TCOC and primary care investment performance data. Meeting all data sharing and reporting requirements will be a pre-requisite for continued participation in the AHEAD Model. CMS will use data that states already report to CMS to reduce state burden. Additional data sharing requirements are included in the NOFO.

    

8. How will quality measures be established for each state?

   Each participating state will select a set of quality and population health measures from a menu of options provided by CMS. States will set specific targets for each selected measure, subject to CMS approval, that they will be accountable for meeting under the AHEAD Model.

   CMS will also use quality measures and other data across the model to monitor impact and protect against any unintended consequences in the care delivered to beneficiaries or any negative changes in healthcare access or costs.

    

9. Is there flexibility in choosing Statewide Quality and Population Health Measures?

   The AHEAD Model recognizes that many states have established population health strategies and strives to align with already existing health equity initiatives. There are two sets of measures in the model: the statewide core set and optional set. The core set is comprised of five domains and will allow latitude in selecting measures within the defined domains. The optional set allows states to select at least one additional measure that is outside of the domain groups. States will choose from the preselected measures and may propose optional measures that better aligns with the unique needs of their population, subject to CMS approval, in determining their statewide quality measures and targets.

    

10. How will individual beneficiary experiences be incorporated into the model?

    Each participating state will be required to comply with the AHEAD Model’s quality and population health strategy, which includes opportunities to report on beneficiary experience. Participating states may choose to report on additional patient-reported outcome measures or other measures related to beneficiary experience. At the provider level, hospitals will use the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which assesses an individual’s care experience.

    Additionally, the model integrates patient voices in model decision-making. States are required to form a multi-sector model governance structure to aid in developing the statewide health equity plan and related population health activities. The structure will include various stakeholders, including community-based organizations and patients. Incorporating diverse perspectives into the design of statewide initiatives increases the likelihood of creating successful public health planning to improve population health.

     

11. How is state performance assessed in the model? 

    CMS will assess state performance on generated savings relative to the state’s projected TCOC growth absent the model. CMS will include state-specific factors (e.g., historic spending) in setting cost growth and primary care investment targets and projected state TCOC growth. TCOC growth and primary care investment targets will apply to the entire state or sub-state region in which the model operates, regardless of the level of participation in hospital global budgets.

    Each participating state will be assessed and held accountable for state-specific Medicare FFS and all-payer cost growth and primary care investment targets. Medicare FFS cost growth targets will include Medicare Part A and Part B expenditures for beneficiaries residing in the state or sub-state region who meet eligibility criteria (e.g., residents in the state for a minimum defined period). All-payer cost growth targets will include expenditures for Medicare FFS, Medicare Advantage, Medicaid, commercial, state employee health plans, and Marketplace-qualified health plans.

    States will be responsible for performance on All-Payer (including Medicaid, commercial, Medicare FFS, and Medicare Advantage) and Medicare FFS primary care investment targets. These targets will be set by measuring primary care expenditures for beneficiaries residing in the state or sub-state region as a percent of state TCOC for those beneficiaries. The Medicare FFS Primary Care Investment Targets will be set by CMS. States will have flexibility to set all-payer targets, subject to CMS approval.

    Award recipients will also be accountable for monitoring, performing, and improving on quality and equity targets set at the statewide or sub-statewide level over the course of the model. CMS will collaborate with participating states to set these targets, which will be reflected in the State Agreement. The state model governance structure will report performance on these targets to CMS as part of annual statewide health equity plan updates. 
     

12. Is this model a replacement for the Vermont All-Payer Accountable Care Organization (VT ACO) Model, the Maryland Total Cost of Care Model (MD TCOC), and the Pennsylvania Rural Health Model (PARHM) models or will those models continue alongside the AHEAD model?

    Vermont, Maryland, and Pennsylvania are eligible to apply to the AHEAD Model as a strategy to sustain the care delivery transformation currently being implemented under these existing models.

    States interested in participating in the AHEAD Model must apply to the NOFO during the application period and be selected as part of the competitive process to receive an AHEAD Cooperative Agreement award and participate in the AHEAD Model. If Vermont, Maryland, and/or Pennsylvania are selected to participate in the AHEAD Model, they may receive Cooperative Agreement funding during the performance periods of the VT ACO, MD TCOC, and PARHM models. However, if Vermont, Maryland, and/or Pennsylvania are selected to participate in the AHEAD Model, the performance periods of the VT ACO, MD TCOC, and PARHM models may not overlap with the AHEAD implementation periods.

     

13. How will the model address health equity and behavioral health?

    AHEAD is designed to drive improvements in health equity through increased investments in activities likely to reduce disparities in health outcomes, including: 

    • Primary care
    • Integration of behavioral health and health-related social needs throughout the model
    • Inclusion of safety net hospitals, Federally Qualified Health Centers (FQHCs), and Rural Health Centers (RHCs)
    • Adjustments for social risk factors impacting health outcomes and spending.

    Participating hospitals and primary care practices will be required to collect demographic and social needs data. This data will be used to identify health disparities and measure progress toward improvement.

    Hospital global budgets will be adjusted based on improvements in equity of health outcomes, as well as quality of care. Participating primary care practices will be required to engage in behavioral health integration activities as a component of Primary Care AHEAD care transformation requirements.

     

14. What are CMS’ expectations for participating states to demonstrate funding sustainability?

    States interested in participating in the model should include a detailed sustainability plan as part of the budget narrative included in their application. The Cooperative Agreement funding issued to AHEAD Model participants during the first five and a half years for Cohorts 1 and 2 and for the first 6 years for Cohort 3 is intended to support the most time and resource-intensive portion of model implementation. CMS recommends states consider strategies to sustain funding and Model activities throughout the implementation period.

     

15. Can states or sub-state regions participating in the AHEAD Model and providers in those states or sub-state regions simultaneously participate in AHEAD and other CMS Innovation Center models or Medicare programs?

    The AHEAD Model may operate statewide or in a sub-state region. The following CMS models and programs can concurrently operate within an AHEAD state or sub-state region, with certain conditions and restrictions:

    • ACO Realizing Equity, Access, and Community Health (ACO REACH)
    • Cell and Gene Therapy (CGT) Access
    • Guiding an Improved Dementia Experience (GUIDE)
    • Innovation in Behavioral Health (IBH)
    • Medicare Shared Savings Program (Shared Savings Program)
    • Primary Care First (PCF)

    The Making Care Primary (MCP) and Transforming Maternal Health (TMaH) models cannot concurrently operate within overlapping geographic regions. The extent to which primary care providers and hospitals can simultaneously participate in AHEAD and other Medicare value-based care initiatives depends on the specific CMMI model or program.

    View our Overlaps Fact Sheet (PDF).

     

16. Which Project Narrative numbering should a state or sub-state region use in its Notice of Funding Opportunity application?

    CMS has realized that the numbering for the Project Narrative in Section D2.d, Project Narrative (page 32) does not match the numbering for the Project Narrative in Section E1, Criteria (page 40). Applicants should default to the Project Narrative numbering in Section E1, Criteria. Applicants will not be penalized for any discrepancies in the Project Narrative numbering included in their application. Applicants will only be reviewed based on the inclusion of all required Project Narrative headers and the associated content.

Hospital Participation in the AHEAD Model

1. How can hospitals and health systems participate?

   During the NOFO application period, hospitals and health systems can consult with applicable state agencies to inform state application to participate in the AHEAD Model. Hospitals and health systems may choose to submit a letter of support that state agencies can include in their application.

   During the AHEAD Model, hospitals and health systems located in a participating state or sub-state may participate in hospital global budgets as a critical mechanism in transforming care delivery and improving population health. A minimum of 10% of a state or sub-state region’s Medicare FFS hospital net patient revenue (NPR) must be under a hospital global budget. This minimum will increase to 30% of Medicare FFS hospital NPR in the fourth performance year. Critical Access Hospitals (CAHs) are eligible to participate in the AHEAD Model’s hospital global budgets. Rural Emergency Hospitals may also participate in states that have enacted enabling legislation. Information on specific eligible provider types is included in the NOFO. Any hospital interested in participating in the AHEAD Model must be a Medicare-enrolled facility in good standing with CMS, among other requirements to be specified in participation agreements and other policy documents. Participating hospitals and health systems will also develop health equity plans to reduce disparities in care and outcomes for the patients and communities they serve. Hospitals must participate in the AHEAD Model, consistent with the NOFO, or CMS may terminate the participating state’s Cooperative Agreement and ability to participate in the model. 

    

2. What is the benefit of participating in the AHEAD Model for hospitals?

   Participating hospitals will benefit from stable and predictable funding through hospital global budgets. Hospitals that chose to participation in the AHEAD Model will also benefit from technical assistance and learning resources that are intended to aid transformation activities. Participation in the model gives hospitals the opportunity to use benefit enhancements available under the model to support care redesign efforts. Participating hospitals may also realize savings generated from reductions in avoidable utilization coupled with gains in care delivery efficiency.

    

3. How are hospital global budgets established and used as part of the AHEAD Model?

   In partnership with participating states, the AHEAD Model will implement Medicare FFS and Medicaid hospital global budgets, while encouraging increased commercial payer alignment, for hospitals that voluntarily choose to participate. States, in consultation with CMS, will be required to develop a Medicaid hospital global budget methodology, with technical assistance (TA) from CMCS and guidance from the Innovation Center. Medicaid hospital global budget methodologies are subject to CMS approval. Medicaid hospital global budgets must be implemented in Performance Year 1 (PY1), after the model pre-implementation period.

   CMS will develop and maintain a standardized Medicare FFS hospital global budget methodology, with modifications for Critical Access Hospitals (CAHs) and other safety net hospitals. A participating hospital’s global budget will be based on historical revenues for eligible services, and will include adjustments for performance accountability (e.g., reductions in avoidable utilization). Hospital global budgets should also account for the unique social and medical risks of the population each hospital serves.

   Hospital global budgets will be paid to participating hospitals in the form of prospective, bi-weekly payments in place of traditional Medicare FFS claims payments. States with hospital rate-setting or hospital budget-setting authority and prior experience in population-based payments or global budgets may develop and implement a state-specific Medicare FFS global budget methodology, subject to CMS approval.

   States’ applications to participate in AHEAD must describe their intended use of state legislative or regulatory authority to facilitate commercial payer participation in hospital global budgets. States participating in the AHEAD Model will be required to have at least one commercial payer participating in hospital global budgets by the start of PY2. This commercial payer can include a state employee health plan, Marketplace Qualified Health Plans, or other payer.

   View our AHEAD Hospital Global Budget Factsheet (PDF).

    

4. Are states required to use hospital global budgets under the AHEAD Model?

   Yes, states participating in the AHEAD Model will be required to use hospital global budgets. This will include implementing a Medicaid hospital global budget by the end of the first performance year and having at least one commercial payer participating in hospital global budgets by the start of the second performance year. Hospital that chose to participate in the AHEAD Model will also be required to receive payments from the Medicare FFS hospital global budget designed by CMS or states with the required hospital rate-setting or hospital budget-setting authority and prior experience in population-based payments or global budgets. A minimum of 10% of a state or sub-state region’s Medicare FFS hospital net patient revenue (NPR) must be under a hospital global budget. This minimum will increase to 30% of Medicare FFS hospital NPR in the fourth performance year.

    

5. How has CMS designed the AHEAD Model to reduce financial risks to participating hospitals?

   
   CMS will provide hospitals that voluntarily participate in the model with upfront financial investments, such as the Transformation Incentive Adjustment (TIA), through the Medicare FFS hospital global budgets to reduce risk while progressing towards model goals in curbing health care cost growth, improving population health, and advancing health equity by reducing disparities in health outcomes. CMS has carefully designed the Medicare FFS hospital global budget methodology to incentivize early participation in the model. CMS may approve additional Medicaid flexibilities to reduce unintended risk to participating hospitals.

   The model’s CMS-designed Medicare FFS hospital global budget methodology includes the TIA and the Health Equity Improvement Bonus. The TIA will be an upward adjustment to a participating hospital’s global budget in the first two years of the model to support enhanced care management for Medicare beneficiaries, which must be repaid if a hospital exits the model prior to the start of the state’s PY6. The Health Equity Improvement Bonus will provide an upward adjustment to a participating hospital’s global budget based on performance on select equity-related measures. Participating CAHs will also be able to participate in upside-only quality adjustment programs that will begin as pay-for-reporting before moving to pay-for-performance in later years of the model.

   The CMS-designed Medicare FFS hospital global budget methodology also includes a performance measure for total cost of care (TCOC) incurred by Medicare FFS beneficiaries residing in the hospital’s service area. The TCOC adjustment for acute care hospitals will start as upside-only in PY4 and will be based on performance in PY2. Downside risk for the TCOC adjustment will be started in PY5 and will be based on performance starting in PY3. For CAHs, downside risk for the TCOC adjustment will begin based on performance in PY4. The CMS-designed Medicare FFS hospital global budget methodology also includes downside risk adjustments for hospital performance on reducing potentially avoidable utilization. Participating hospitals will continue to be accountable for performance under CMS’ national hospital quality programs as well.

    

6. How will CMS protect against stinting of care or decrements in quality of care provided under hospital global budgets? 

   State and hospital accountability for TCOC growth, quality, and population health outcomes under the AHEAD Model is intended to ensure beneficiaries benefit from enhanced quality and access to hospital and acute care, not stinting or decrements in quality of care. Hospital global budgets provide incentives to keep beneficiaries healthy and out of the hospital, to reduce complications during hospitalizations, and to better coordinate care at hospital discharge to prevent readmissions. In addition, hospital global budgets will be adjusted over time to account for changes in the patient population served, services provided, and performance across quality, health equity, TCOC performance and other domains.

   The AHEAD Model’s statewide accountability targets for cost growth and quality will be set through collaboration with providers, payers, and the community to create tenable goals that prioritize beneficiary experience and quality of care. Participating hospitals are required to continue participating in CMS’ Hospital-Acquired Condition Reduction Program (HACRP), Hospital Readmissions Reduction Program (HRRP), Hospital Inpatient Quality Reporting Program (IQR), Hospital Outpatient Quality Reporting Program (OQR), and Hospital Value-Based Purchasing Program (VBP) and will be held accountable for performance by CMS.

   CMS will monitor for unintended consequences including, but not limited to, changes in the provision of appropriate services; worsened performance on population health outcomes, access, and quality measures and targets; exacerbation of inequities; care stinting; limiting beneficiary choice; and improper sharing of private beneficiary health information.

    

7. How does Total Cost of Care accountability work in the AHEAD Model? Is TCOC limited only to hospitals that participate in Hospital Global Budgets?

   The AHEAD Model includes state accountability for Medicare FFS and All-Payer Total Cost of Care (TCOC) Growth Targets across the state or selected sub-state region. These targets will be negotiated between CMS and each award recipient during the pre-implementation period. In addition, hospitals voluntarily participating in Medicare FFS global budgets are accountable for Medicare FFS TCOC for beneficiaries residing in their service area through a performance adjustment to the global budget. Hospital accountability for TCOC performance will be phased in over the course of the model, starting with upside-only risk for participating hospitals, and it is not intended to disrupt existing accountable care relationships.

   Statewide Medicare FFS and all-payer TCOC spending accountability is intended to ensure that overall health care spending does not increase while participants rebalance health care spending across the system, implement hospital global budgets, and increase primary care investments. CMS will work with each award recipient during the pre-implementation period to set Medicare FFS Growth Targets, building from a common CMS methodology as described in the NOFO and which will be outlined in the State Agreement. The statewide Medicare FFS Growth Targets will include all Medicare FFS spending (Parts A and B) for beneficiaries residing in the state or sub-state region who meet certain eligibility criteria. Participating states or sub-state regions will be accountable for annual All-Payer TCOC Growth Targets for Medicare, Medicaid, and commercial payer growth, which must be memorialized in state Executive Order, statute, or regulatory change in advance of the first Performance Year (PY) and must be sustained for the duration of the Implementation Period. Both the Medicare FFS and the All-Payer TCOC Targets will be described in the State Agreement.

   Hospitals take on accountability for beneficiaries’ cost of care and outcomes as part of the hospital global budget methodology through a performance adjustment. See the question below (How has CMS designed the AHEAD Model to reduce financial risks to participating hospitals?) and the NOFO for more information.

   For additional information about the Total Cost of Care methodology and Hospital Global Budgets, please visit our Key Concepts page.

CMS-Designated Medicare FFS Hospital Global Budget

1. How is the CMS-Designed Medicare HGB calculated for Performance Year (PY) 1?

   To construct the CMS-Designed Medicare HGBs for Participant Hospitals, CMS will first calculate a Participant Hospital’s global budget baseline by combining the hospital’s historical revenue from Medicare FFS payments from the three most recent years prior to joining the AHEAD Model. CMS will weight historical revenue, weighting the most recent years more heavily (i.e., Base Year (BY) 1: 10%; BY 2: 30% and BY 3: 60%). Historical revenue paid by CMS outside the FFS framework (e.g., non-claims-based payments, beneficiary out-of-pocket payments) are excluded from the HGBs and will continue to be paid separately.

   CMS will include the baseline inpatient and outpatient paid amounts for which Medicare is the primary payer for the relevant BYs. Professional services rendered in a hospital setting are not included in the CMS Designed Medicare FFS HGB and will continue to be paid FFS. For a list of detailed payments excluded from global budgets see Appendix D in the CMS Designed Medicare FFS Hospital Global Budget Financial Specifications Version 2.0.

   Once the baseline is calculated, CMS will make a series of adjustments to account for differences between the BYs and PY1. These adjustments include an Annual Payment Adjustment (APA) to account for changes in Medicare FFS prices and policy, Volume-Based Adjustments to account for changes in population size and demographics, shifts in services between hospitals, and AHEAD Specific Adjustments including Social Risk Adjustment and a Transformation Incentive Adjustment. See Section 2.2 in the CMS-Designed Medicare FFS Hospital Global Budget Financial Specifications Version 2.0 for additional information on adjustments made to the baseline.

   For more details on how CMS will calculate the HGB for PY1 see Section 2.1.1 in the CMS Designed Medicare FFS Hospital Global Budget Financial Specifications Version 2.0.

    

2. How will the CMS-Designed Medicare FFS HGB be calculated differently starting in PY2?

   CMS will use each hospital’s PY1 HGB as the starting point for the PY2 HGB. As with the calculation for PY1, CMS will apply the Annual Payment Adjustment (APA), Volume-Based Adjustments including the Demographic Adjustment, Market Shift/Unplanned Volume Change, and Service Line changes. AHEAD specific adjustments will also apply including the Social Risk Adjustment, Transformation Incentive Adjustment and Performance-Based Adjustments including those for CMS’ national quality programs, Health Equity Improvement Bonus, the Effectiveness Adjustment for performance on Potentially Avoidable Utilization (PAU), and Total Cost of Care (TCOC) performance. Many of the adjustments applied to the HGB will be phased in over time. For more information as to when adjustments will be made in the HGB calculation, please reference Exhibits 40-42 in the AHEAD Model Hospital Global Budget Financial Specifications Version 2.0.

   For more information on Performance-Based Adjustments, see Section 2.3 in the CMS-Designed Medicare FFS Version 2.0 Technical Specifications. Additionally, Critical Access Hospitals (CAHs) will have separate quality and TCOC performance adjustments, for details see Sections 2.3.1, 2.3.4, and Exhibit 41. For each PY, a CAHs HGB payment amount will also include a payment floor that is no less than 101% of CAH costs (prior to sequestration or what would have been paid by Medicare FFS had the CAH not participated in AHEAD). If the HGB payment amount is less than 101% of CAH costs, CMS will make an additional payment to the CAH equal to the difference. See Section 2.1.5.

    

3. What provider types are eligible for participation in the AHEAD Medicare HGB?

   The following table describes which hospital types are eligible or ineligible for participation in the CMS-Designed Medicare FFS HGB. Hospital participation in AHEAD is voluntary and will be subject to state-level coordination and oversight.

   Eligible Hospital Types	Ineligible Hospital Types
   Acute Care Hospitals Critical Access Hospitals Medicare-Dependent Hospitals Rural Emergency Hospitals Rural Referral Center Programs Sole Community Hospitals Tribal Hospitals Indian Health Service Hospitals	Cancer Hospitals Children’s Hospitals Long-Term Care Facilities Psychiatric Hospitals (free standing and distinct part units) Rehabilitation Hospitals (free standing and distinct part units) Transplant Hospitals Veterans’ Hospitals

4. In Version 2.0 of the CMS-Designed Medicare FFS HGB Financial Specifications considered final or will changes still be made?

   Version 2.0 of the CMS-Designed Medicare FFS HGB Financial Specifications builds on Version 1.0 by increasing the clarity of the methodology, improving transparency and predictability, and, thereby, reducing risk for hospitals considering participation in the AHEAD Medicare HGBs. CMS will continue iterating on the specifications and encourages stakeholders to continue to offer recommendations for refinement of the methodology by contacting AHEAD@cms.hhs.gov. There is a planned release for Version 3.0 that will include additional recommendations made by stakeholders. For more information on Version 3.0, please see question seven. Additionally, if a decision is made to release an update to the methodology, interested parties will be informed via email through the AHEAD Model listserv and on the AHEAD Model webpage. To sign up to receive email notifications through the AHEAD Model listserv, please visit this link.

    

5. What are the major differences between the AHEAD Medicare HGB Financial Specifications Version 1.0 and Version 2.0?

   Version 2.0 includes changes that improve specificity, clarity, transparency, and predictability in the financial methodology. There are eight key revisions:

   • Baseline Period for the AHEAD Medicare HGB Shifted Forward Six Months: The AHEAD Medicare HGB Baseline is shifted forward by six months and includes a completion factor that improves accuracy of initial global budgets. This allows for more accurate and straightforward forecasting of PY1.
   • Part B Drugs Carveout Now Only Excludes Cancer Drugs: The Part B carveout now only excludes cancer drugs that represent a significant and highly variable portion of hospital spending, reducing risk for hospitals. This change balances the risk to hospitals posed by high-cost cancer drugs, with the goal that the global budget be inclusive of most hospital spending.
   • Annual Payment Adjustment (APA) Higher of Uncompensated Care (UCC)/ Disproportionate Share Hospital (DSH): The methodology uses the higher of UCC) and DSH payment factors from the Inpatient Prospective Payment System (IPPS) Final Rule when calculating the change in CMS prices as part of the APA. This improves payment stability for hospitals by ensuring that UCC/DSH adjustments are not lower than any previous years during the model.
   • Enhancements to the Demographics Adjustment: Adjustments for demographic changes no longer apply retrospectively after the PY, improving predictability for hospitals.
   • Social Risk Adjustment (SRA) and Total Cost of Care (TCOC) Geography: The SRA and TCOC adjustments now use the same geographic definitions as the Market Shift Adjustment, helping to align aspects of methodology.
   • Market Shift Adjustment Out-of-Area Geography Now Excludes Outliers: The methodology now includes a 120-mile distance and 1% out-of-area threshold excluding from the calculation patients receiving care that is outside of the ability for the hospital to coordinate or control (e.g., snowbirds). This change also provides more consistency in the market definition.
   • Payment Floor for Critical Access Hospitals (CAHs): The payment floor ensures that HGB payments for CAHs are no lower than current Medicare FFS reimbursement at 101% of costs (before sequestration). The floor is calculated such that if the HGB payments for the performance year are less than what would have been paid by Medicare FFS had the CAH not participated in the HGB, CMS will make an additional payment to the CAH equal to the difference.

   • Standardized Area Deprivation Index (ADI): CMS is using a standardized ADI to reduce rural-urban differences due to prices, improving equity.

      

6. What changes can I expect in version 3.0 and when will that be released?

   In Q1 of 2025, CMS plans to share Version 3.0 of the Financial Specifications that, as of today, will outline updates to the following items:
   o    Increased Alignment of Quality Measures
   o    Total Cost of Care Adjustment Benchmark and Geography
   o    Continued Refinement of Market Shift Adjustment

   Please refer to Section 1.1 of the AHEAD Model Hospital Global Budget Financial Specifications Version 2.0 for more information about the planned updates. CMS continues to welcome stakeholder feedback to further enhance future specification releases through contacting AHEAD@cms.hhs.gov.

   For Hospital Participants:

7. Before my hospitals must make a participation decision, will we receive information about our estimated AHEAD Medicare HGB amounts and how it compares to FFS revenue?

   Prior to participation decision deadlines, CMS and the state will provide hospitals with additional information including estimated CMS-Designed Medicare HGB FFS payment amounts to inform participation decisions. Hospitals considering participation in Cohort 1 will finalize participation decisions by November of 2025.

    

8. As a health system, we have a clinically integrated network (CIN) of primary care physicians. Can practices in the CIN participate in the Primary Care (PC) AHEAD Model even if the system’s hospitals choose not to participate in AHEAD Model HGBs?

   In addition to other eligibility requirements detailed on the AHEAD Model website, practices that are owned by a hospital or health system can only participate in PC AHEAD if that hospital is a Participant Hospital under the AHEAD Model global budgets. Hospital or health-system affiliated FQHCs and RHCs are exempted from this requirement. Affiliated practices that are not owned may otherwise participate if they meet the eligibility criteria.

    

9. Where should hospitals go for additional questions related to the AHEAD Model financial methodology?

   For more information regarding the AHEAD Medicare HGB financial methodology, hospitals can refer to the following resources. As additional materials become available, including additional technical assistance, they will be posted on the AHEAD Model webpage.

   • CMS-Designed Medicare FFS HGB Version 2.0 Financial Specifications: provides a detailed description of the financial methodology and operational payment features of Medicare Fee-For-Service HGBs under the Model. It aims to provide eligible applicants, providers, and interested parties with the necessary details to understand the financial aspects of the AHEAD Model.
   • AHEAD Medicare HGB Webinar Version 2.0: the AHEAD Model website includes postings of previous webinars. The AHEAD Medicare HGB Webinar Version 2.0 slides will be posted in late July 2024 along with the recording and transcript following the webinar.
   • AHEAD Help Desk: Hospital should submit any questions about the AHEAD Medicare HGB Methodology to the AHEAD Help Desk: AHEAD@cms.hhs.gov. When submitting Help Desk questions, participating hospitals and practices should include the state in the subject line to ensure answers are most applicable to their situation. Subject matter experts will respond to questions in a timely manner to provide AHEAD Model guidance.
   • AHEAD HGB Fact Sheet: (PDF) provides an overview of the key components of the AHEAD HGB.

Primary Care Participation in the AHEAD Model

1. How do the AHEAD Model’s primary care strategies differ from other CMS primary care models?

   The AHEAD Model builds on lessons learned from existing state-based models, including the Maryland Total Cost of Care Model, the Vermont All-Payer ACO Model, and the Pennsylvania Rural Health Model. The model’s flexible framework enables states to leverage existing state innovations while testing a suite of new interventions across all states. It offers states the opportunity to curb growth in health care spending, improve population health, and advance health equity by reducing disparities in health outcomes. AHEAD differs from previous Innovation Center models in three specific ways: establishing a specific goal of increasing statewide primary care investment in proportion to the total cost of care, pairing hospital global budgets with advanced primary care, and offering a flexible framework to implement advanced primary care in alignment with the state’s existing Medicaid primary care program activities. For more information, see the below graphic comparing the Innovation Center’s primary care models.

   • View our Primary Care Comparison Infographic (PDF)

      

2. How can primary care practices participate in the model? 

   Primary care practices interested in participating in the AHEAD Model should consult with the applicable state agency eligible to apply. Primary care practices must participate simultaneously in the state Medicaid advanced primary care program or Primary Care Medical Home (PCMH) program to be eligible for participation in Primary Care AHEAD.

   Primary care practices located in a state or sub-state region selected to participate in AHEAD may voluntarily participate in Primary Care AHEAD. Eligible practices will be identified at the Tax Identification Number (TIN) level, except system-owned practices, which will also be identified by National Provider Identifier (NPI). Health system-owned practices may only participate in Primary Care AHEAD if the health system’s hospitals are participating in the hospital global budgets in the same performance year. System-owned FQHCs and RHCs will be exempted from this requirement.

    

3. Can other provider organizations, such as Federally Qualified Health Centers (FQHCs), participate in Primary Care AHEAD?

   Yes. FQHCs, including Health Centers and Health Center Look-Alikes (as defined by HRSA), and RHCs located in participating states and sub-state regions are eligible to participate in Primary Care AHEAD. FQHCs and RHCs that choose to participate in Primary Care AHEAD will do so in the same way as non-safety net primary care practices.

    

4. How will primary care practices and staff benefit from participation in AHEAD?

   Through participation in Primary Care AHEAD, primary care practices will receive prospective, flexible, and enhanced payments intended to increase their capacity to deliver advanced primary care services for all attributed Medicare Part B beneficiaries. The model payments will fund care transformation in care coordination, behavioral health integration, and health-related social needs interventions, all tailored to the priorities of the state Medicaid Primary Care APM or Patient-Centered Medical Home (PCMH) program. This will also give participating practices the opportunity to hire staff to provide team-based, whole-person care, increase their quality reporting and performance capacities, and strengthen their coordination with specialty providers and community-based organizations.

    

5. What criteria are required for the Medicaid primary care Alternative Payment Model (APM) or Patient-Centered Medical Home (PCMH) program?

   An applicant’s Medicaid primary care APM or PCMH program should focus on enhanced care coordination services, including behavioral health integration and health-related social needs interventions. It should focus on delivery of whole-person, team-based, anticipatory primary care services. CMS plans to allow for some variation between these state Medicaid primary care APMs and PCMH programs and has designed the care transformation and quality requirements in Primary Care AHEAD to be tailored to the specific care transformation priorities of the state.

   Applicants will need to include:

   • Description of the applicant’s current primary care transformation initiatives and goals under their Medicaid Primary Care APM.
   • Description of applicant’s plan for aligning Primary Care AHEAD care transformation goals to current Medicaid primary care initiatives. 
   • Description of specific tools that will be used to increase primary care investment in Medicaid.
   • Identification of specific policy tools that will be used to increase access to primary care services.
   • Description of existing or planned programs for the state’s Medicaid Primary Care APM that will be implemented by the start of PY1.

   View our AHEAD Primary Care Payment Factsheet (PDF).

    

6. What level of detail is needed to describe the state regulatory changes, federal flexibilities, or waiver authorities required to implement hospital global budgets for Medicaid?

   Applicants will be required to describe the state’s capacity to develop and implement a Medicaid hospital global budget methodology, which must begin payments by the end of PY1 as part of their application. Applicants should include the proposed authority or mechanism for making payments and considerations for the state’s unique Medicaid context (e.g., population in managed care or FFS). Please see Appendix VIII in the NOFO for more information about the Medicaid Alignment Criteria for Hospital Global Budgets, the associated Model Milestones, and the process for obtaining the required federal authorities.

    

7. How will the AHEAD Model define and measure primary care investment to set Medicare FFS and All-Payer Primary Care Investment Targets?

   The AHEAD Model’s primary care definition for spending measurement, and the associated Medicare FFS spending estimates, are available to download on the AHEAD Model webpage (XLSX). This definition will be used for Medicare FFS primary care investment measurement and target setting. States can propose their own primary care definitions for All-Payer Primary Care Investment Targets but are encouraged to align as closely as possible with the AHEAD methodology and definition. Please note that state estimates of primary care spending based on the AHEAD Model’s definition are not a required or scored part of the NOFO application.

    

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