Waivers for Health Care Delivery Innovation
Table of Contents
Recent News Spotlight:
OneCare Vermont Announces Six New Waivers to Improve Health Care Quality and Access
OneCare Vermont has introduced six new waivers aimed at improving mental health care access, reducing hospital readmissions, and enhancing overall health care accessibility in Vermont, allocating $100,000 to fund innovative projects to achieve these goals
About Waivers
OneCare Vermont, as an accountable care organization (ACO) participating in Vermont’s All-Payer Model, has been provided waivers—known as “Fraud and Abuse Waivers” and “Benefit Enhancement Waivers”—that are specific to the Vermont All-Payer Model. These waivers are provided to make it easier for the health care providers who work with OneCare to provide high quality care at lower costs to Vermonters.
Using the waivers, OneCare has been able to support new care delivery projects for patients like free medical nutrition counseling, genomic testing and counseling, and personal care services – all of which are restricted under federal rules and regulations. The waivers have also been used to promote partnerships between providers like ambulance transport from the emergency department to treatment, or providing care in the home to patients who don’t qualify for home health or sharing data and analytics tools.
The intention is to promote delivery system innovation amongst unrelated provider organizations (like between a hospital and a designated agency) working together on cost and quality of care as part of the OneCare Vermont ACO in Vermont’s All-Payer Model. Unrelated provider organization arrangements that meet the criteria of these waivers are protected from enforcement under Anti-Kickback, Stark and Civil Monetary Penalties laws.
After considering the specific needs in Vermont, OneCare has determined that, although it will consider any waiver request, it is particularly interested in using waivers to help patients leave the hospital when they are ready for step down care. This includes transportation, paying for needed medications at skilled nursing facilities, and providing support at home once patients return there.
The Waiver Tools and How OneCare Uses Them
Participation Waiver
This waiver offers flexibility provided by Medicare and Medicaid to allow OneCare Vermont and its participants to create financial and clinical arrangements that promote success in the Vermont All-Payer Model without risking regulatory penalties; in other words, giving providers more flexibility in improving the value of care. The participation waiver removes detailed requirements and allows participating providers to be creative and design pathways for delivering care that improve the care experience while more efficiently spending health care resources.
Laws waived: Anti-Kickback Statute & Stark Law: these laws govern financial relationships between providers for Medicare and VT Medicaid patients
Eligible population: Medicare, VT Medicaid, Commercial
Eligible ideas: Arrangements for clinical services, IT, and social services can be made between OneCare and/or OneCare participant with or without other parties.
Conditions:
- OneCare must be in a participation agreement with Medicare and Medicaid and meeting their governance requirements
- OneCare’s Board of Managers must determine the arrangement is “reasonably related to ACO activities,” which generally are activities that further the All-Payer Model
- The arrangement and board approval must be documented contemporaneously
- Description of the arrangement must be posted on OneCare website
How to utilize this waiver:
Providers must partner with the ACO in order to take advantage of the Participation Waiver.
Patient Engagement Incentives Waiver
The Patient Engagement Incentives Waiver allows participating providers to give their patients services and items for free where they are preventive or advance clinical goals without dollar limits.
Laws Waived: Civil Monetary Penalties and Anti-Kickback Statute for Medicare and VT Medicaid patients.
Eligible Populations: Medicare, VT Medicaid, Commercial
Conditions:
- OneCare must be in a participation agreement with Medicare & Medicaid
- There must be a reasonable connection between the item or service given for free and the patient’s medical care
- Actual in-kind items or services must be given (no gift cards, coupons, cash or cash equivalents; no copay or deductible waivers).
- Items or services given for free must be:
- 1) Preventive, or
- 2) Advance one or more of following clinical goals:
- Adherence to treatment regimen;
- Adherence to drug regimen;
- Adherence to follow up care plan;
- Management of chronic disease or condition
- The ACO must have records to show that conditions have been met
- The beneficiary must reasonably perceive the item or service to be from ACO or participant
How to utilize this waiver:
Providers must partner with the ACO in order to take advantage of the Patient Engagement Incentives Waiver.
Currently Approved Waivers
Getting Patients the Right Type of Care
Preventive Care
Nursing Home Care
Substance Use Disorder Care
Mental Health Care
At-Home Care
Getting Patients the Right Preventive Care:
Increasing Access to Telehealth Ocular Care for Diabetic Patients Routine Retinopathy Screening
With a participation waiver and award funding from OneCare, Porter Medical Center primary care practices is able to deploy an ocular telehealth with retinal camera in their offices, using it to screen adult diabetic patients for retinopathy at routine visits. UVMMC Ophthalmology interprets the images and transmits a patient management plan to the primary care office.
Board approved resolution to authorize utilization of participation waiver: 2019 Innovation Project Fraud and Abuse Waivers – May 2019
Increasing Access to Annual Wellness Visits
Utilizing a participation waiver and award funding from OneCare Vermont to launch program and pay for nurse’s time, Cathedral Square wellness nurses work with residents’ primary care providers from Appletree Bay Primary Care and Community Health Centers of Burlington to provide Medicare Annual Wellness Visits.
Board approved resolution to authorize utilization of participation waiver: 2024 Cathedral Square Medicare Waiver
Genomic Screening to Advance Preventive Care
Genomics identifies variations or mutations that might be causing disease, resulting in more accurate diagnosis that may allow providers to choose a therapy that specifically targets the underlying cause of a patients’ conditions, potentially increasing the effectiveness of treatment and decreasing side effects. A patient engagement incentives waiver made it possible for the University of Vermont Medical Center to provide primary care patients genomics reports and counseling related to their genomic specific health data. “Genomic Care Pathway” reports provided to participating patients and their physicians/providers to assist in interpretation of results and to guide any additional testing or monitoring pertinent to the specific positive gene screening.
Board approved resolution to authorize utilization of participation waiver: 2019 Genomics Resolution – May 2019
Getting Patients the Right Nursing Home Care:
Getting Patients Out of Inpatient and to the Right Nursing Home Care by Sharing Medication Costs
Participations waivers make it possible for the University of Vermont Medical Center to pay for room and board and/or medication (antibiotics/infusion drugs) post-discharge to skilled nursing facilities (SNFs), facilitating transfers from inpatient facilities that might otherwise be denied because the cost of medication is more than the daily rate paid to SNFs for their services. This means patients are more quickly getting the more appropriate care for their needs. This is care that is more affordable for the health care system.
Board approved resolution to authorize utilization of participation waiver: 2024 UVMMC-Birchwood Participation Waiver; 2023 5d. Resolution to Approve UVMMC-Birchwood Participation Waiver – December 2023; 2023 Participation Waiver for Hospital Discharge – September 2023
Resolution Invoking Participation Waiver for UVMMC to Pay Room Board for Patient Discharged to Birchwood July 2024
Funding to Increase Clinical Services at Skilled Nursing Facilities
A participation waiver allowed OneCare to provide $50,000 each to four skilled nursing facilities to support them in increasing clinical services for their residents.
Board approved resolution to authorize utilization of participation waiver: 2023 Participation Waiver for Support of Clinical Coverage for Network Skilled Nursing Facilities – September 2023
Getting Patients the Right Substance Use Disorder and/or Mental Health Care:
Establishing a Child Psychiatry Consultation Clinic to Support Pediatricians and Primary Care Physicians with Delivering the Right Mental Health Care
A waiver and funding from OneCare have made it possible for Community Health Centers of Burlington (CHCB) to operate a child psychiatry consultation clinic providing diagnostic evaluation and consultation to pediatric patients. The psychiatry clinic interacts with and assists pediatricians and primary care physicians with addressing their patients’ needs.
Board approved resolution to authorize utilization of participation waiver: 2019 Innovation Project Fraud and Abuse Waivers – September 2019
Funding of TeleFriend Tablet for Post-Discharge Support
With a participation waiver and funding from OneCare, the Brattleboro Retreat has been able to provide patients with a TeleFriend tablet for post discharge support. A project clinician works in conjunction with the tablet’s programming to identify signs of decompensation based on the patient’s input. The clinician responds according to an established protocol that can include referrals to additional treatment.
Board approved resolution to authorize utilization of participation waiver: 2019 Innovation Project Fraud and Abuse Waivers – September 2019
Establishing Urgent Psychiatric Care for Children Transported from Schools
With a participation waiver and funding from OneCare, United Counseling Services piloted a psychiatric urgent care center to address the increasing utilization of emergency department care for children transported from schools for disruptive behaviors.
Board approved resolution to authorize utilization of participation waiver: 2019 Innovation Project Fraud and Abuse Waivers – May 2019
Establishing Treatment Paths for Alcohol Use Disorder
With a participation waiver and funding from OneCare, Southwestern Vermont Medical Center and Turning Point have partnered to create an alcohol use disorder treatment path from inpatient detoxification through residential treatment after discharge. Patients are supported by trained recovery counselors through the treatment path.
Board approved resolution to authorize utilization of participation waiver: 2023 5b. Resolution to approve Participation Waiver SVMC – December 2023
Getting Patients Out of Emergency Departments and to the Right Hospital Inpatient Care
Utilizing a participation waiver, Southwestern Vermont Medical Center (SVMC) has been able to pay Rescue Inc. transportation services a capacity fee to have an ambulance and crew available to take patients in emergency departments to inpatient treatment at SVMC.
Board approved resolution to authorize utilization of participation waiver: 2023 Resolution Expanding the Brattleboro Retreat Participation Waiver – October 2023
Getting Patients Out of Emergency Departments and to the Right Mental Health and Substance Abuse Care at the Brattleboro Retreat
Utilizing a participation waiver, the University of Vermont Medical Center has been able to pay a fee for Rescue Inc. transportation services to increase its transport hours, taking patients from emergency departments to the Brattleboro Retreat for voluntary inpatient treatment. This gets patients in need of mental health and/or substance abuse treatment out of emergency departments and to the right care for their needs. And that’s not all: the Rescue, Inc crew are specially trained and the vehicle is appropriately outfitted to best support the condition and symptoms of the patients. Transport hours include nights and weekends.
Board approved resolution to authorize utilization of participation waiver: 2023 Participation Waiver for Transport from Network Hospital Emergency Departments to the Brattleboro Retreat for Treatment – February 2023 2019 Innovation Project
Getting Patients the Right At-Home Care:
Establishing a Community Paramedic Program to Extend Care Coordination to At-Risk Patients
A waiver and funding from OneCare have made it possible to plan a Community Paramedic (CP) program to extend care coordination to at-risk patients. The CP initially identifies patients at the hospital emergency department and provides in-home services after discharge. The CP cooperates with primary care to provide orders for care and follow up.
Board approved resolution to authorize utilization of participation waiver: 2019 Innovation Project Fraud and Abuse Waivers – September 2019
Getting 24-hour Remote Monitoring for Mental Health Patients Returning to Home
With a participation waiver and funding from OneCare, UVM Home Health and Hospice and partners have been able to pilot an acute home care program, allowing patients who would otherwise be hospitalized or admitted to skilled nursing facilities to receive care in home.
Board approved resolution to authorize utilization of participation waiver: 2019 Innovation Project Fraud and Abuse Waivers – September 2019
Establishing In-Home Treatment Paths to Avoid Stays at Hospitals or Nursing Homes
With a participation waiver and funding from OneCare, UVM Home Health and Hospice and partners have been able to pilot an acute home care program, allowing patients who would otherwise be hospitalized or admitted to skilled nursing facilities to receive care in home.
Board approved resolution to authorize utilization of participation waiver: 2019 Innovation Project Fraud and Abuse Waivers – September 2019
Additional Board Approved Waivers for Ongoing ACO Activities
- 2019 Fraud and Abuse Resolution – January 2019
- 2020 Fraud and Abuse Resolution – January 2020
- 2021 Fraud and Abuse Resolution – January 2021
- 2022 Fraud and Abuse Resolution – January 2022
- 2024 6a. Resolution Invoking Participation Waiver for 2024 Program of Payment and Supporting Arrangements – February 2024
Application
Note: This application form is for ACO participants only.