Waivers for Health Care Delivery Innovation

Patient Engagement Incentives Waiver

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.

Apply now

Examples Participation Waiver Utilization:

Brattleboro Retreat Ambulance Transport: Patients in emergency departments (EDs) were stuck waiting for rides to get the right substance use treatment and mental health care at the Brattleboro Retreat. A participation waiver made it possible for hospitals to pay a local, independent ambulance company to transport patients efficiently and in an appropriate transportation setting by specially trained staff. Patients, the Brattleboro Retreat, and local EDs have all delivered positive feedback on this arrangement and emergency room crowding has been reduced. Read more: Getting Vermonters in crisis out of emergency departments and into the right mental health care – OneCare Vermont (onecarevt.org)
Hospital Funds Post-Discharge Medications at SNFs: Patients in hospitals that are ready to be transferred to skilled nursing facilities (SNFs) are sometimes delayed because SNFs are paid a daily rate for their services, but some patients’ medications cost more than the daily rate and it is not economically feasible for the SNF to accept the patients. Meanwhile, if the patient cannot be discharged, the in-patient provider incurs extensive costs and is not paid for those services. So, in the case of University of Vermont Medical Center, they used a participation waiver to allow them to pay for post-discharge medications at the SNF, clearing the in-patient bed and getting patients to the right care for their needs.

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; IV. 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.

Apply now

Examples of Utilization of Patient Engagement Incentives Waiver:

Medical Nutrition Therapy: Medicare outpatients can often benefit from medical nutrition therapy not covered by Medicare. Patients can receive medical nutrition therapy from registered dieticians thanks to a Patient Engagement Incentives Waiver. The waiver allows these services to be provided for free, easing the financial burden for seniors.
Personal Care Attendants – Facilitate Discharge: A Patient Engagement Incentives Waiver allows hospitals to contract with non-health care provider home services companies who provide the support at home for patients, at no cost to the patients and paid for by the hospitals. This waiver supports patients who do not qualify for skilled nursing facilities or home health but need extra care at home to be discharged from the hospital.
Genomics Project: 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 was used at University of Vermont Medical Center to provide primary care patients genomics reports and counseling related to their genomic specific health data.