Health Living

LEAD’s Healthy Living Strategy encompasses prevention, beneficiary engagement, and technology adoption: a multi-pronged approach to promoting health beyond the claims-and-savings framework. (RFA §VII.E)

Benefit Enhancements (RFA §VII.E.2)

LEAD carries forward 8 benefit enhancements from ACO REACH, each requiring ACO opt-in:

1. 3-Day SNF Rule Waiver: Waives the Medicare requirement for a 3-day inpatient hospital stay before a beneficiary can receive covered SNF or swing-bed services. Allows ACOs to place beneficiaries in SNF directly when clinically appropriate. (RFA §VII.E.2)
2. Telehealth: Allows beneficiaries to receive telehealth services from their home (not just originating sites). Covers certain asynchronous telehealth services. Expands access for rural and homebound beneficiaries. (RFA §VII.E.2)
3. Post-Discharge Home Visits: Enables home visits within 90 days following discharge from an inpatient facility. Designed to reduce readmissions and support care transitions. (RFA §VII.E.2)
4. Care Management Home Visits: Supports home-based care management visits for ongoing chronic disease management outside of the post-discharge window. (RFA §VII.E.2)
5. Home Health Homebound Waiver: Relaxes the Medicare homebound requirement for certain clinically appropriate beneficiaries, allowing home health services for patients who may not meet the strict homebound definition. (RFA §VII.E.2)
6. NP/PA Expanded Services: Allows nurse practitioners and physician assistants to certify and order 6 types of care (RFA §VII.E.2):
   • Hospice care certification
   • Diabetic shoes certification
   • Cardiac rehabilitation care plan
   • Home infusion therapy plan
   • Medical nutrition therapy referrals (for diabetes/renal disease)
   • Pulmonary rehabilitation care plan
7. Concurrent Care for Hospice: Allows beneficiaries who have elected the Medicare Hospice Benefit to concurrently receive curative care. Under standard Medicare rules, electing hospice generally means forgoing curative treatment. (RFA §VII.E.2)
8. Medical Nutrition Therapy: Allows NPs and PAs to make referrals for medical nutrition therapy for beneficiaries with diabetes or renal disease (normally requires a physician referral). (RFA §VII.E.2)

Patient Incentives (RFA §VII.E.3)

CMS expects the Anti-Kickback Statute Safe Harbor for CMS-sponsored model patient incentives (42 C.F.R. § 1001.952(ii)(2)) to apply to LEAD patient incentives. (RFA §VII.E.3)

In-Kind Items and Services

LEAD ACOs may provide non-cash items or services to aligned beneficiaries if ALL of the following conditions are met: (RFA §VII.E.3)

• Direct connection between the item/service and the beneficiary’s medical care
• Supports prevention or management of a chronic condition, adherence to treatment/drug regimen, follow-up care plan, or disease management
• Is NOT a Medicare-covered item or service (including items coverable under a Benefit Enhancement)
• Is NOT furnished to reward the beneficiary for voluntary alignment designation
• Must NOT include cash or cash equivalents
• Must be furnished directly by the ACO, Participant TIN, Participant Provider, Preferred Provider, or an organization with a written agreement with any of these entities

Funded by the ACO or its participating providers.

Chronic Disease Prevention ($150 Maximum)

ACOs may provide healthy food products (up to $150 value) to incentivize participation in evidence-based programs: chronic disease self-management, tobacco cessation, daily exercise, weight loss, A1c reduction. (RFA §VII.E.3)

Delivery methods: Direct distribution of healthy food products OR a restricted-spend card limited to healthy food purchases (cannot be used for general purposes).

Requirements: ACOs must submit an Implementation Plan to CMS for approval. Must maintain records of the program including amounts, types of food/cards offered, and basis for beneficiary eligibility. Subject to monitoring and compliance activities. The program must not discriminate against any aligned beneficiary who otherwise qualifies.

Part B Cost-Sharing Support

ACOs may reduce or eliminate beneficiary cost-sharing for specific high-value Part B services to incentivize care from ACO providers. (RFA §VII.E.3)

How it works: Participant TINs, Participant Providers, or Preferred Providers agree (via a written cost-sharing support agreement with the ACO) not to collect some or all of the beneficiary’s cost-sharing amount for specified Part B services. The ACO makes payments to those providers to cover the uncollected amount.

Requirements: ACOs must submit an Implementation Plan identifying: eligible beneficiary categories, eligible Part B service categories (both primary care and specialty care may be included), and how ACO and provider contributions will be determined if cost-sharing is not covered in full. Implementation Plan subject to CMS approval. ACOs may establish simplified Preferred Provider Agreements specifically for cost-sharing support purposes (without requiring capitation arrangements).

Tech Enabler link: CMS envisions ACOs using care navigation tools (via the Tech Enabler Initiative) to help beneficiaries identify high-value providers where cost-sharing support applies.

Substance Access

ACOs may recommend and provide Eligible Hemp Products to certain beneficiaries as a complement to traditional treatments. (RFA §VII.E.3)

Eligible Hemp Products must meet the 2018 Agriculture Improvement Act definition: Cannabis sativa L. with delta-9-THC ≤0.3% dry weight; excludes products with >3mg/serving of other THC compounds in oral form; excludes inhalable products; excludes synthetic cannabinoids. Must meet state/local quality laws, come from a legally compliant source, and be third-party tested for potency, contaminants (pesticides, heavy metals, solvents), and microbials.

Eligible Beneficiaries must be: 18+ years old, not exhibiting signs of frailty, free of disqualifying conditions, and have had a documented shared decision-making discussion with their physician.

Disqualifying conditions: substance abuse disorders (alcohol, cannabis, opioid, tobacco use disorder), active pulmonary conditions (COPD, asthma, ILD, emphysema), serious mental illness (schizophrenia, schizoaffective, delusional, bipolar, severe anxiety, MDD with suicidality, active psychosis), cognitive impairment/dementia, severe cardiovascular disease (symptomatic arrhythmia), severe liver disease, severe kidney disease (CKD stage 3+), pregnancy/breastfeeding. (RFA §VII.E.3)

Only applicable in states where hemp is legal. Requires CMS-approved Implementation Plan.

Benefit Enhancements Under Consideration for Future Years

CMS has signaled it may introduce additional enhancements in future performance years. These are not available at PY 2027 launch but are worth monitoring: (RFA §VII.E.4)

Enhancement	Description	Earliest Availability
Part D Premium Buydown	ACOs could share savings with beneficiaries by reducing Part D prescription drug plan premiums (average ~$460/year). Available to higher-spending ACOs and “High-Value Care Champion ACOs” (top 30% savings + quality requirement). Designed to improve medication adherence.	2029 (estimated)
DMEPOS Flexibility	Streamlined administrative requirements for durable medical equipment, prosthetics, orthotics, and supplies to reduce delays in access. Particularly relevant for High Needs beneficiaries who use DMEPOS at higher rates.	TBD
Annual Wellness Visit Flexibility	Allow AWV on a calendar-year basis instead of once every 12 months. Reduces administrative burden of tracking 12-month intervals.	TBD
Beneficiary Savings Program	Direct financial incentives (e.g., health savings account contributions, premium/copay reductions) for beneficiaries who engage in high-value activities: lifestyle changes, physical activity goals, selection of high-value providers or lower-cost care sites.	TBD
Other Substance Access	Expansion of the Substance Access incentive to other medically approved substances beyond hemp products.	TBD

CMS welcomes stakeholder feedback on these and other potential enhancements.

Tech Enabler Initiative New in LEAD (RFA §XV.A)

CMS will support identification of high-value technology and AI use cases, facilitate connections between ACOs and technology vendors, and promote adoption of digital health tools, data analytics, and AI-powered care management capabilities. This is an ACO support service provided by CMS, not a payment mechanism.