CHART Model Community Transformation Track in Texas

Status of the CHART Model in Texas

As of September 30, 2023, the Community Health Access and Rural Transformation (CHART) Model ended nationwide. On March 17, 2023, the Center for Medicare and Medicaid Innovation (CMMI) within the Centers for Medicare and Medicaid Services (CMS) announced the federal CHART Model will end earlier than expected due to a lack of participation nationwide. CMS’ termination notice is posted on the CMS Innovation Center website.

The CHART Model was envisioned as a 7-year federal funding opportunity for eligible rural hospitals to voluntarily participate to test health care transformation supported by payment reform through implementation of alternative payment models (APMS) in Medicare and Medicaid.

The deadline for hospitals to sign a Participation Agreement to join Performance Period 1 (Calendar Year 2023) of the CHART Model was Nov. 1, 2022. Unfortunately, no Texas rural hospitals opted to join the Model for this year. HHSC surveyed potential Participant Hospitals in Texas on factors considered in the hospitals’ decision-making and communicated these results to CMS for their consideration. HHSC and CMS are working to identify lessons learned to incorporate in future models. Updates and information about HHSC’s work with CMS and rural providers will be added to this site.

In September 2021, HHSC received the CHART Model Community Transformation Track Award to implement the Model in Texas as the Lead Organization. HHSC began recruitment of potential Participant Hospitals for the CHART Model on Oct. 1, 2021. HHSC’s robust recruitment efforts consisted of sending multiple notices and emails to stakeholders on CHART Model updates, responding to stakeholder inquiries regarding the CHART Model, presenting and attending at Texas Organization of Rural and Community Hospitals (TORCH) conferences, hosting one-on-one meetings with potential Participation Hospitals, facilitating topic-focused meetings with potential Participant Hospitals including a Financial Readiness Panel and Q&A session with CMS, distributing key information regarding the CHART Model such as an estimated and final Medicare Capitated Payment Amount to potential Participant Hospitals, and consistently posting new information and materials on the HHSC CHART Model website.

If interested in additional information about HHSC’s recruitment efforts for the CHART Model in 2022, please review the HHSC CHART Model Pre-Implementation Resources.

CHART Model Funding Tracks

The CHART Model was a voluntary funding opportunity from CMS for rural communities to test health care transformation supported by payment reform.

  • The Community Transformation Track – Designed to provide award recipients with cooperative agreement funding and a programmatic framework to assess the needs of their Community and implement health care delivery system redesign. This track builds on the lessons from the Maryland Total Cost of Care Model and Pennsylvania Rural Health Model. CMS announced the termination of the Community Transformation Track in March 2023. Lead Organizations, such as Texas, will exit the Model by September 2023. Please visit the CMS website for more information.
  • The Accountable Care Organization (ACO) Transformation Track – Designed to provide upfront payments to rural ACOs that join the Medicare Shared Savings Program. This track builds on lessons learned from the ACO Investment Model. CMS announced the removal of the ACO Transformation Track from the CHART model in February 2022.

CHART Model Community Transformation Track

The CHART Community Transformation Track was originally envisioned to provide rural hospitals with three ways to transform their local health care system:

  1. Regular lump sum payments based on a hospital’s Medicare fee-for-service income (a.k.a. capitated payment amount)

    CMS originally planned replacing Medicare fee-for-service claims reimbursement for Participant Hospitals with regular, lump sum payments also called a “capitated payment amount (CPA)” throughout the duration of the CHART Model. The CHART Model CPA would be calculated by CMS, not HHSC. The benefit of this payment change to hospitals would be that the CPA payment would provide stability and predictability, as well as the freedom to invest in new service lines and utilize regulatory flexibilities offered by the CHART Model initiative. For example, hospitals may have had to focus on providing higher-reimbursing specialty services over essential primary care and improving behavioral health capacity or maintaining inpatient beds to meet Medicare conditions of participation, even when it may not be what is needed in the community.
  2. Cooperative Agreement Funding

    As the CHART Model Lead Organization for Texas, HHSC planned to disperse up to $2.7 million in cooperative agreement funding to participant hospitals. Participating hospitals would then use the funding to establish partnerships and technical support to address one or more health challenges in the Texas CHART application to establish a telemedicine project that fits the needs of the hospital's county, and to address health disparities and selected social determinants of health.
  3. Operational Flexibilities

    CMS intended to make available certain operational flexibilities to expand Lead Organizations’ ability to implement health care delivery system redesign and promote participating hospitals’ capacity to manage their patients’ care. Lead Organizations, like HHSC, would be responsible for requesting operational flexibilities in their Transformation Plans in consultation with Participant Hospitals.

    These flexibilities would be provided through a combination of the Model Design Flexibilities listed in the notice of funding opportunity and through CMMI’s authority under section 1115A(d)(1) of the Act to waive certain Medicare and Medicaid requirements, solely as may be necessary to test the Model. CMMI may have waived such requirements of Titles XI and XVIII and of sections 1902(a)(1), 1902(a)(13), 1903(m)(2)(A)(iii), and provisions of section 1934 that were added to section 1115A(d)(1) by the PACE Innovation Act as may be necessary solely for purposes of carrying out section 1115A with respect to testing models described in section 1115A(b).

CHART Model Award

Since no hospitals participated in the CHART Model, CMS allowed Lead Organizations, such as HHSC, the option to use CHART Model funds by September 30, 2023, to advance the Strategic Priorities previously approved by CMS. In this effort, HHSC used the funding to advance rural hospitals’ knowledge about Telehealth and Alternative Payment Models (APMs).

HHSC provided scholarships to 41 staff from 11 rural hospitals to receive the Frontiers in Telemedicine Training, securing two rural APM subject matter experts who presented at the fall 2023 Texas Organization of Rural and Community Hospitals (TORCH) Conference. HHSC also provided two scholarships for two rural physicians to attend the conference.

As the Lead Organization, HHSC was to receive up to $5 million in cooperative agreement funding. HHSC’s goal was to use much of the cooperative agreement funding to:

  • Provide technical assistance to hospitals related to transformation
  • Allow hospitals to purchase telemedicine equipment, training, software and hire additional staff, if needed, to implement transformation goals

If successful, residents of participating rural communities would see improvement in access to health care services, financial stability of providers and an alignment of payers and other stakeholders to address both the communities’ needs and social support structures, such as food and housing, to ensure improved health. Ultimately, the CHART Model’s purpose was to bring improved financial stability to participant rural hospitals through capitated arrangements and provide strategies to address health challenges through telemedicine. Through the CHART Model, health care providers, as well as public and private payers, could collectively invest in increasing access to care, promoting quality and improving the health outcomes of residents within their Community.

The estimated project period was originally intended to be Oct. 1, 2021 through Dec. 31, 2028.

HHSC’s CHART Model application and supplementary materials are included below. It is recommended to view the CHART Model application requirements on pages 51 – 59 of the CHART Model Notice of Funding Opportunity before viewing HHSC’s application. These pages show the information HHSC was required to include in its application.

The following additional resource materials prepared by HHSC in advance of HHSC’s CHART Model application provide more detail on HHSC’s planned approach for implementing the CHART Model in Texas.

CHART Model Advisory Council

Recognizing that stakeholder engagement is key to effective reform, the CHART Model required an Advisory Council to be established. The multi-stakeholder group advised HHSC, the state’s Lead Organization, about certain deliverables and topics related to the CHART Model. The Council was required to meet quarterly, and its purpose was to provide critical feedback in the development and implementation of Texas’ CHART Model Transformation Plan and assist with collaboration efforts with Participant Hospitals and other key stakeholders. Other activities the Council was intended to contribute to were: recruiting hospitals and Aligned Payers, developing APM ideas, identifying technical assistance needs of participating hospitals related to their telemedicine projects and Community health challenges, and monitoring the progress of the Model. Summaries from the Council meetings will be posted after each meeting.

CHART Model and Rural Health Care Resources