CCTP: Frequently Asked Questions (FAQs)

This document contains some of the most frequently asked questions about eligibility requirements and proposal development for the Community-based Care Transitions Program. These questions do not represent an exhaustive summary of Program requirements and should be used for guidance on specific issues. For additional questions or clarification on those listed below, please direct questions to CareTransitions@cms.hhs.gov.

What is the definition  of a Medicare Fee-for-Service (FFS) beneficiary? Are beneficiaries eligible for care transition services if they have Medicare Part A but do not have Medicare Part B coverage?

A Medicare FFS beneficiary is defined in the legislation authorizing the Community-based Care Transitions Program (CCTP) as a beneficiary with Medicare Part A and B and not Part C. For this reason CMS will only be able to pay care transition services for those beneficiaries with both Medicare Part A and Medicare Part B.  In addition, given that most care transition interventions promote a timely physician follow up visit post hospital discharge, it is critical that outpatient coverage is available to CCTP beneficiaries and that CMS has access to the outpatient claims for tracking and evaluation purposes. It is acceptable to put together an application that includes some beneficiaries that have Medicare Part A only.  In such cases CMS will account for the slightly inflated volume when reviewing applications.

Is participation in the Community Based Care Transition Program (CCTP) limited to the acute care hospitals listed in the high readmission hospital file posted on the program webpage?

No. If a Community Based Organization (CBO) is the applicant, the CBO is not limited to working with the hospitals on the high readmission hospital file. However, an acute care hospital is only eligible to apply as the primary applicant if it is on the posted high readmission hospital file.  In either scenario there must be a partnership between a CBO and at least one acute care hospital in a community.

Would a University working in partnership with an acute care hospital, and Community-Based Organization (CBO) be eligible to apply to be the recipient and lead organization for the Community Based Care Transition Program (CCTP)?

A university would not generally qualify as the eligible entity. The statute defines an eligible entity as an acute care hospital or an appropriate CBO.  In order to be eligible to participate in the CCTP, a CBO is required to partner with at least one acute care hospital.  A CBO could also partner with other downstream providers, educational institutions or others, but is not required to do so. If the university houses an Aging & Disability Resource Center (ADRC) or other program funded by the Administration on Aging it may be eligible.

Can my organization participate in the CCTP if we are already participating in another demonstration or pilot?

Yes, participation in other demonstrations or pilots does not exclude you from participating in the CCTP.  If such other demonstration or pilot shares Medicare savings with you, that demonstration or pilot may offset savings with expenditures under CCTP.  Please refer to the rules governing the specific demonstration or pilot for further information.

How do you define continuum of care? Does this include acute hospitals, nursing homes, home health, community-based organizations? Are you expecting CBOs to coordinate across "all" settings?

The nursing home discharge is a completely different set of client needs than a discharge home; could we focus on one discharge location? Yes, hospitals, nursing homes, home health, SNF, and hospice are all part of the continuum of care, and we expect CBOs to coordinate across all settings. Beneficiaries often experience multiple transitions following discharge from the hospital and therefore a CBO must follow that beneficiary across various settings if there is any hope of reducing avoidable admissions.

Does a coalition representing a collaboration of community healthcare providers qualify as a CBO?

Does a coalition representing a collaboration of community healthcare providers (medical centers, Federal Qualified Health Centers (FQHCs), health plans, educational leaders and local government) qualify as a Community-Based Organization (CBO)?If the coalition is (1) a legal entity, such as a 501(c) (3) organization or other organization that has a taxpayer identification number and can accept payment, (2) has a governing body that includes broad community representation of multiple health care stakeholders, including consumers and (3) is physically located in the community it proposes to serve, then it could qualify as a CBO.  In addition, there must be adequate consumer representation on the governing board with voting rights. The consumers may not be providers or immediate family members of providers to satisfy this requirement.

What kind of legal entity is required to meet the definition of Community-Based Organization (CBO)? We have a network of providers that have agreed to participate in this program and so far have had positive success in reducing readmissions. What kind of legal entity is required to meet the definition of Community-Based Organization (CBO)?

The legal entity could be a 501(c)(3) organization or other organization that has a taxpayer identification number, can accept payment, and meets the other requirements to qualify as a CBO as described in our response to FAQ# 10418.

What is the minimum/maximum number of partners you are willing to accept?

The general model we are looking for is one CBO working with multiple acute care hospitals in a geographically contiguous area representing a community. We would consider a consortium of multiple CBOs each working with different acute care hospitals if that model made sense given the geographic spread proposed in the application. There would need to be one lead CBO that would coordinate the services and billing for all CBOs in the consortium and interface with CMS and its contractors. For all awards CMS will only pay one CBO. Therefore, this approach would result in a lot of additional work by the lead CBO which would need to distribute the payments to all the CBOs in the consortium. There would have to be some clear advantage to this model over having separate applications over a large geographic area for it to be accepted.

Does an Area Agency on Aging  (AAA) or Aging and Disability Resource Center (ADRC) that is governmentally based and whose governing board is composed of elected officials qualify as a community based organization (CBO)?

Yes, a governmentally based AAA or ADRC whose governing body is composed of elected officials does qualify as a CBO for the CCTP.  We believe that elected officials serving on these governing bodies are inherently representative of the communities they serve, including health care stakeholders and consumers in their respective communities.

What is involved in a root cause analysis?

A root cause analysis may include but is not limited to the following methods and elements: medical record review; analysis of admission and discharge data; process assessment including process owner interviews and direct observation; and focus groups with patients and providers.  The root cause analysis should identify patterns of readmissions specific to a particular community and its providers.  The results of the root cause analysis should be used to guide targeting criteria and intervention selection.

Does an advisory board with consumer representation suffice as the governing body required of CBO? How about a steering committee?

No.  We do not believe that having an advisory board or steering committee that includes representatives from multiple healthcare stakeholders, including consumers, would satisfy the statutory requirement under section 3026(b)(1)(B) of the Affordable Care Act, that the governing body of the CBO include sufficient representation of multiple healthcare stakeholders.   To satisfy the clear intent of the statute, healthcare stakeholders, including consumers, must be represented on a body that has the legal authority to govern the CBO.  Because advisory boards and steering committees, by definition, do not have legal authority to govern the CBO, stakeholder representation on these types of bodies would not be sufficient to satisfy the statutory requirement.

What is the significance of the hospitals in bold type above the dotted line in the high readmission hospital file? What is the significance of the numbers 2 or 3?

The hospitals listed in bold type positioned above the dotted line with a number 3 next to them are those hospitals that fell in the fourth quartile for their state on all three Hospital Compare readmission measures (AMI, HF, PN).  The remaining hospitals in the list fell in the fourth quartile for their state on 2 out of 3 Hospital Compare readmission measures (AMI, HF, PN).

What time period does the data represent that was used in the high readmission hospital file?

The data covers 30 day readmission rates for hospitalizations that occurred between July 1, 2005 and June 30, 2008 and is the most current data available via Hospital Compare.

Can the Community-Based Organization (CBO) that is the applicant agency subcontract out to other CBOs who are doing the actual transitional care work?

The applicant agency CBO would be an administrator, central organizer, and recipient of funding prior to subcontracting out to CBO partners in the field. Yes that is acceptable; however, the applicant would need to demonstrate that each proposed subcontractor possessed expertise in the delivery of care transition services.

Does a home health provider qualify as a Community-Based Organization (CBO)?

A home health agency would only qualify as a CBO if it was based in the community it proposed to serve and had a governing body with broad community representation of multiple health care stakeholders, including consumers. To ensure broad stakeholder involvement, 50% of the board representation should come from outside the home health agency.  Please also see our response to FAQ# 10418 for guidance on consumer representation.

Could a Chronic Care Management Program be considered having expertise in care transitions?

Experience with chronic care management/disease management is not synonymous with care transitions experience. The per eligible discharge rate is meant to cover a relatively short term intense intervention around admission to and discharge from an acute care hospital. This rate would not support an ongoing chronic care management program which usually requires a per member per month payment for an indefinite period.

Can a CBO partner with acute care hospitals that are not on the high readmission hospital file?

Yes. A CBO can partner with any and all acute care hospitals in the community it proposes to serve.

What is required in order to meet the requirement of “multiple health care stakeholders"?

Experience thus far tends to show that efforts to improve care transitions work best when there is a genuine collaboration among the medical and social services providers in a community.  We are not setting a specific threshold for the number or distribution of health care stakeholders that participate in a CBO, in part because many communities do not have ready access to Medicare or all-payer data that would allow them to track patient use of various services across time.  However, applications will be strengthened when applicants can show that the initial participants represent most of the settings in which Medicare beneficiaries in the community receive care, as well as other services that may be available to support care transitions for these beneficiaries.  We anticipate that this will usually include at least hospitals, home health agencies, nursing homes, physicians, hospices, and supportive services such as housing and aides in the community.

Does a Quality Improvement Organization (QIO) qualify as a Community-Based Organization (CBO)?

A QIO operating as a QIO does not qualify as a CBO for this program.  The business entity that holds a QIO contract could qualify as a CBO and apply for this program as a separate and distinct line of business.  The entity would need to have a substantial physical presence in the community it proposed to serve and meet the definition of CBO as provided in our responses to FAQ #10418 and FAQ #10419.  In addition, we would need to ensure that there would be no conflict of interest between the business entity’s activities under the CCTP and its operations as a QIO under the QIO statute.  For example, we would need to ensure that as part of its activities under the CCTP the business entity would not be entering into any business or legal relationships with health care entities that might bias the entity’s ability to perform its QIO functions under Title XI.

When you refer to the establishment of formal relationships with hospitals, how do you define "formal"? What are the minimum requirements to validate a formal relationship?

We need to see evidence in the application that the hospital leadership is on board with the proposal. Therefore, we have required letters of commitment from the CFO, CEO, and operations manager responsible for discharges of every hospital partner proposed in the application.

Could an applicant propose a smaller scale implementation, with a proposal to expand slowly over the course of 2 or 3 years?

We cannot guarantee later expansions because of the finite resources available for the program and the rolling admissions provision. We will be making awards based on applicants' "not to exceed rates" for program participation which are derived from anticipated volume of beneficiaries to be served at each partner hospital and will continue awarding applications until we reach our budget capacity. It is true that not all awardees will continue to operate beyond the initial 2-year agreements and that we will redirect some of those dollars to organizations that have demonstrated success for the purposes of expansion.

Are applicants limited to proposing one of the evidence-based care transitions models referenced in the solicitation? What if you would like to propose a model that has been adapted from an evidence-based model, and would be implemented with adherence to evidence-based components but also accommodating for site-specific variability?

No. Applicants can propose any intervention that they can demonstrate will likely reduce avoidable hospital readmissions and improve transitions of care for Medicare beneficiaries. Adaptations of evidence-based models are acceptable if such adaptations are necessary to accommodate community specific factors that have been identified through the applicant's root cause analysis.

Should we assume that hospitals or CBO's that don't meet the criteria will not hold as much weight in regards to overall scoring of the applications?

The words "preference" and "consideration" are used interchangeably throughout the solicitation when referring to various eligibility criteria. Should we assume that hospitals or CBO's that don't meet these criteria will not hold as much weight in regards to overall scoring of the applications; in other words, would you discourage them from applying?

We do not wish to discourage any eligible CBO from applying. The preference and consideration are applied when all else is equal between two applications. This will become more of a factor as we approach our budget ceiling and there is only enough funding to select one of the two.

Are critical access hospitals eligible for the Community Based Care Transition Program (CCTP)?

The statutory language in 3026 specifically targets subsection (d) acute care hospitals. Critical access hospitals and specialty hospitals are excluded. Critical access hospitals could still participate in the broader community effort by partnering with the eligible CBO in their community. However, the CBOs will only be paid care transition fees for beneficiaries intervened upon immediately following discharge from a partnering acute care hospital.