Medicare Advantage Value-Based Insurance Design Model

The Medicare Advantage (MA) Value-Based Insurance Design (VBID) Model will terminate at the end of 2025. For more information, please see our latest blog post. CMS is committed to supporting a seamless experience for all enrollees in VBID Model-participating plans, and will build on lessons learned from the VBID Model.

Important VBID Model Resources:

VBID: Innovating to Meet Person-Centered Needs

Through the Medicare Advantage (MA) Value-Based Insurance Design (VBID) Model, CMS is testing a broad array of MA health plan innovations that aim to enhance the quality of care for Medicare enrollees—including those with low income, such as dually eligible enrollees and those qualifying for Low Income Subsidy (LIS)—and reduce costs for enrollees and the overall Medicare program.

The VBID Model contributes to the modernization of MA and tests whether these model components improve health outcomes and lower costs for MA enrollees.

For Calendar Year (CY) 2025, the VBID Model has 62 participating Medicare Advantage Organizations (MAOs) projecting to offer over seven million enrollees additional Model benefits and/or rewards and incentives as part of the Model test in 2025.

Click for a full list of CY 2025 participants
  • Alignment Healthcare USA, LLC
  • AllCare Health, Inc.
  • AlohaCare
  • Athena Healthcare Holdings, LLC
  • Aware Integrated, Inc.
  • Banner Health
  • Baylor Scott & White Holdings
  • Blue Cross Blue Shield of Arizona
  • BlueCross BlueShield of Tennessee
  • Blue Cross & Blue Shield of Rhode Island
  • CareSource
  • California Physicians' Service
  • Clever Care Health Plan, Inc.
  • Centene Corporation
  • Chinese Hospital Association
  • Community Health Plan of Washington
  • The Cigna Group
  • Community Health Group
  • Corewell Health
  • CVS Health Corporation
  • Devoted Health, Inc.
  • Denver Health and Hospital Authority
  • Doctors HealthCare Plans, Inc.
  • Elevance Health, Inc.
  • Guidewell Mutual Holding Corporation
  • Healthfirst, Inc.
  • HealthPartners, Inc.
  • Henry Ford Health System
  • Highmark Health
  • Hawaii Medical Service Association
  • Health Plan of CareOregon, Inc.
  • Humana Inc.
  • Independence Health Group, Inc.
  • Inland Empire Health Plan
  • Louisiana Health Service & Indemnity Company
  • Local Initiative Health Authority for LA County
  • Medica Holding Company
  • MHH Healthcare, L.P.
  • Molina Healthcare, Inc.
  • MVP Health Care, Inc.
  • New York City Health and Hospitals Corporation
  • Ochsner Clinic Foundation
  • Orange County Health Authority
  • Point32Health, Inc.
  • Providence St Joseph Health
  • PrimeWest Rural MN Health Care Access Initiative
  • Risant Health, Inc.
  • Sanford Health
  • Santa Clara County Health Authority
  • South Country Health Alliance
  • The Health Plan of West Virginia, Inc.
  • Thomas Jefferson University
  • Triton Health Systems, L.L.C.
  • UCare Minnesota
  • Ultimate Healthcare Holdings, LLC
  • UNICO Services, Inc.
  • UnitedHealth Group, Inc.
  • Universal Health Services, Inc.
  • UPMC Health System
  • Village Care of New York, Inc.
  • Visiting Nurse Service of New York
  • Zing Health Consolidator, Inc
 

Highlights for CY 2025

  • A variety of factors including financial strain, limited access to healthy foods and transportation and/or unmanaged chronic health conditions, can prevent patients from seeking health care. Medicare Advantage (MA) plans aim to address these challenges, but current rules make it hard to reach certain patients.
  • The MA Value-Based Insurance Design (VBID) Model helps to remove obstacles to health and health care. For instance, under the VBID Model, participating MA plans may provide patients with tailored supplemental benefits such as lower costs for prescription drugs; grocery assistance to help ensure their unmet medical needs and nutrition needs are met; transportation services to make sure they can attend medical appointments; and support managing chronic health conditions.
  • MA plans in VBID are innovating to meet person-centered needs. When health, social and additional factors are addressed as part of a person-centered approach to care, patients may more easily access the care they need — when they need it — to manage their health.

Background on Medicare Advantage (MA)

MA plans offer Medicare beneficiaries an alternative to Original Medicare. In addition to covering all Medicare services, some MA plans also offer enrollees extra coverage through supplemental benefits such as vision, hearing, and dental services. Some MA plans may offer prescription drug coverage (Part D) as part of their plan.

MA plans can charge different out-of-pocket costs for certain services within guidelines defined by Medicare. Value-Based Insurance Design (VBID) generally refers to health insurers’ efforts to structure cost-sharing and other health plan design elements to encourage enrollees to use the services that can benefit them the most.

Currently, Medicare Beneficiaries may enroll into MA and have access to all Original Medicare benefits plus additional supplemental benefits beyond what original Medicare covers. Historically, when an MA enrollee elects hospice, Fee-For-Service (FFS) Medicare becomes responsible for most services while the MA organization retains responsibility for certain services (e.g., supplemental benefits). This hospice “carve-out” from MA results in a convoluted set of coverage rules for MA enrollees who elect hospice and fragments accountability for care and financial responsibility across the care continuum that the Hospice Benefit Component of the VBID Model seeks to address.

VBID Model Details

The VBID Model tests a broad array of MA service delivery and/or payment approaches and contributes to the modernization of MA through increasing choice, lowering cost, and improving the quality of care for Medicare enrollees.

The VBID Model allows participating MAOs to further target benefit design to enrollees based on one or more chronic health conditions, or (ii) Low-Income Subsidy (LIS) eligibility (or, in the territories, dual eligibility for both Medicare and Medicaid), (iii) place of residence in the most underserved ADI areas, or (iv) a combination of chronic health conditions, socioeconomic status, and/or ADI area residence. MA plans participating in the VBID Model may also use reward and incentive programs to encourage enrollees to participate in Part D health-related activities.

For more details on these Model Components please see the links to the Requests for Applications (RFA) below.

Hospice Benefit Component

The Centers for Medicare & Medicaid Services (CMS) announced in January 2019 that beginning in CY 2021, through the VBID Model Hospice Benefit Component, participating MAOs could include the Medicare hospice benefit in their Part A benefits package. After careful consideration, CMS has decided to terminate the Hospice Benefit Component as of 11:59 PM, December 31, 2024.

A list of VBID Model Hospice Benefit Component plans that participated in CY 2021 through CY 2024, as well as downloadable list of PBPs with service area and contact information which can be found here: VBID CY2024 Hospice Benefit Contact Information (XLSX)

By including the Medicare hospice benefit in the MA benefits package, CMS tests the impact on service delivery and quality of MA plans providing all original Parts A and B Medicare items and services required by statute. Additionally, CMS is testing how the Hospice Benefit Component can improve beneficiary care through greater care coordination, reduced fragmentation, and transparency in line with recommendations by the Office of Inspector General (OIG), the Medicare Payment Advisory Commission (MedPAC), and others.

CMS required that MAOs provided beneficiaries with broad access to the complete Original Medicare hospice benefit. Participants were required to outline how they would provide palliative care to eligible enrollees, irrespective of hospice election , and make transitional concurrent care services as well as hospice-specific supplemental benefits available to enrollees who elected hospice through in-network hospice providers.

For technical and operational guidance, please reference the Hospice Benefit Component Technical and Operational Guidance (PDF) and the CY 2024 Technical and Operational Guidance Supplement (PDF). For more guidance on the conclusion of the Hospice Benefit Component, please see the Announcement on Terminating the Hospice Benefit Component and the CY 2024 Technical and Operational Guidance on the Conclusion of the Hospice Benefit Component (PDF).

Visit the Hospice Benefit Component overview page for further information.

Information for Interested Parties

If you are interested in receiving CMS Innovation Center updates, including about the VBID Model, subscribe to the CMS Innovation Center listserv.

For any questions, please email the VBID Model team at VBID@cms.hhs.gov.

CY 2025 Materials

CY 2024 Materials

Additional Information

The separate, OIG-issued, fraud and abuse waivers applicable to Medicare Advantage Organizations in the VBID Model are available at https://www.cms.gov/medicare/physician-self-referral/fraud-and-abuse-waivers. 

CMMI has released a memorandum (PDF) providing guidance on Model treatment of reductions in Part D cost-sharing. CMMI released an additional memorandum (PDF) on December 1, 2022, providing further guidance and examples regarding the reporting of VBID Model benefits in the Prescription Drug Event (PDE) data. Please be aware that the CY 2024 PDE reporting guidance that CMS released as a result of the Inflation Reduction Act (IRA) should be referenced in conjunction with the prior VBID PDE reporting guidance. For example, Example 6 in the December 1, 2022, VBID PDE Reporting Guidance is no longer relevant for 2024 and beyond due to the removal of beneficiary cost-sharing in the catastrophic phase.

CMMI released a memorandum (PDF) on April 8, 2024 to provide guidance on the use of a VBID reporting adjustment in CY 2024. With this adjustment, participating MAOs should not have beneficiaries who remain in the Coverage Gap Phase indefinitely as a result of applying the VBID Model Benefit.

Effective January 1, 2025, VBID cost-sharing reductions will be TrOOP-eligible and must be reported in the Other TrOOP field. CMMI released a memorandum (PDF) on May 20, 2024 to provide guidance and examples of this change.

Webinars

CY 2025 Webinars & Recordings

CY 2024 Webinars & Recordings

 

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