CMS Innovation and Health Care Delivery System Reform

CMS Innovation and Health Care Delivery System Reform Maine Chapter of the American Health Information Management Association March 17, 2 016 Andy Finnegan CMS RO1

Better. Smarter. Healthier. So we will continue to work across sectors and across the aisle for the goals we share: better care, smarter spending, and healthier people.

CMS support of health care Delivery System Reform will result in better care, smarter spending, and healthier people Historical state Evolving future state Public and Private sectors Key characteristics Producer-centered Incentives for volume Unsustainable Fragmented Care Systems and Policies Fee-For-Service Payment Systems Key characteristics Patient-centered Incentives for outcomes Sustainable Coordinated care Systems and Policies Value-based purchasing Accountable Care Organizations Episode-based payments Medical Homes Quality/cost transparency 3

Delivery System Reform requires focusing on the way we pay providers, deliver care, and distribute information { } Improving the way providers are incentivized, the way care is delivered, and the way information is distributed will help provide better care at lower cost across the health care system. FOCUS AREAS Pay Providers Deliver Care Distribute Information Source: Burwell SM. Setting Value-Based Payment Goals HHS Efforts to Improve U.S. Health Care. NEJM 2015 Jan 26; published online first. 4

What is MACRA? The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a bipartisan legislation signed into law on April 1 6, 2015. What does Title I of MACRA do? Repeals the Sustainable Growth Rate (SGR) Formula Changes the way that Medicare rewards clinicians for value over volume Streamlines multiple quality programs under the new Merit- Based Incentive Payments System (MIPS) Provides bonus payments for participation in eligible alternative payment models (APMs) 5

CMS has adopted a framework that categorizes payments to providers Category 1: Fee for Service No Link to Value Category 2: Fee for Service Link to Quality Category 3: Alternative Payment Models Built on Fee-for-Service Architecture Category 4: Population-Based Payment Description Payments are based on volume of services and not linked to quality or efficiency At least a portion of payments vary based on the quality or efficiency of health care delivery Some payment is linked to the effective management of a population or an episode of care Payments still triggered by delivery of services, but opportunities for shared savings or 2-sided risk Payment is not directly triggered by service delivery so volume is not linked to payment Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (e.g., 1 year) Medicare Fee-for- Service examples Limited in Medicare feefor-service Majority of Medicare payments now are linked to quality Hospital valuebased purchasing Physician Value Modifier Readmissions / Hospital Acquired Condition Reduction Program Accountable Care Organizations Medical homes Bundled payments Comprehensive Primary Care initiative Comprehensive ESRD Medicare-Medicaid Financial Alignment Initiative Fee-For- Service Model Eligible Pioneer Accountable Care Organizations in years 3-5 Maryland hospitals Source: Rajkumar R, Conway PH, Tavenner M. CMS engaging multiple payers in payment reform. JAMA 2014; 311: 1967-8. 6

During January 2015, HHS announced goals for value-based payments within the Medicare FFS system 7

Target percentage of payments in FFS linked to quality and alternative payment models by 2016 and 2018 Alternative payment models (Categories 3-4) FFS linked to quality (Categories 2-4) All Medicare FFS (Categories 1-4) 2011 2014 2016 2018 0% ~20% 30% 50% ~70% >80% 85% 90% Historical Performance Goals 8

CMS will achieve Goal 1 through alternative payment models where providers are accountable for both cost and quality Major APM Categories 2014 2015 2016 2017 2018 Accountable Care Organizations Medicare Shared Savings Program ACO* Pioneer ACO* Comprehensive ESRD Care Model Next Generation ACO Bundled Payments Bundled Payment for Care Improvement* Specialty Care Models Advanced Primary Care Comprehensive Primary Care* Multi-payer Advanced Primary Care Practice* Other Models Maryland All-Payer Hospital Payments* ESRD Prospective Payment System* Model completion or expansion CMS will continue to test new models and will identify opportunities to expand existing models * MSSP started in 2012, Pioneer started in 2012, BPCI started in 2013, CPC started in 2012, MAPCP started in 2011, Maryland All Payer started in 2014 ESRD PPS started in 2011 9

CMS is aligning with private sector and states to drive delivery system reform CMS Strategies for Aligning with Private Sector and states Convening Stakeholders Incentivizing Providers Partnering with States 10

The Health Care Payment Learning and Action Network will accelerate the transition to alternative payment models Medicare alone cannot drive sustained progress towards alternative payment models (APM) Success depends upon a critical mass of partners adopting new models Network Objectives Match or exceed Medicare alternative payment model goals across the US health system -30% in APM by 2016-50% in APM by 2018 The network will Convene payers, purchasers, consumers, states and federal partners to establish a common pathway for success Identify areas of agreement around movement to APMs Collaborate to generate evidence, shared approaches, and remove barriers Develop common approaches to core issues such as beneficiary attribution Create implementation guides for payers and purchasers Shift momentum from CMS to private payer/purchaser and state communities Align on core aspects of alternative payment design 11

Accountable Care Organizations: Participation in Medicare ACOs growing rapidly 423 ACOs have been established in the MSSP and Pioneer ACO programs* 7.9 million assigned beneficiaries This includes 89 new ACOS covering 1.6 million beneficiaries assigned to the shared saving program in 2015 ACO-Assigned Beneficiaries by County * April 2015 12

Medicare Shared Savings Program: Results to date Financial Results In 2014: 92 ACOs (28%) held spending $806 million below their targets and earned performance payments of more than $341 million In 2013 1 : 58 ACOs (26%) held spending $705 million below their targets and earned performance payments of more than $315 million Quality Results ACOs that reported in both 2013 and 2014 improved average performance on 27 of 33 quality measures Quality improvement was shown in such measures as patients ratings of clinicians communication, beneficiaries rating of their doctor, screening for tobacco use and cessation, and screening for high blood pressure 1 2013 figures include both 2012 and 2013 savings / loss generated for some ACOs that started mid-year in 2012 (these were the first ACOs in the program) 13

Pioneer ACOs meet requirement for expansion after two years and continued to generate savings in performance year 3 Pioneer ACOS were designed for organizations with experience in coordinated care and ACO-like contracts Pioneer ACOs generated savings for three years in a row Total savings of $92 million in PY1, $96 million in PY2, and $120 million in PY3 Average savings per ACO increased from $2.7 million in PY1 to $4.2 million in PY2 to $6.0 million in PY3 Pioneer ACOs showed improved quality outcomes Mean quality score increased from 72% to 85% to 87% from 2012 2014 Average performance score improved in 28 of 33 (85%) quality measures in PY3 Elements of the Pioneer ACO have been incorporated into track 3 of MSSP 19 ACOs operating in 12 states (AZ, CA, IA, IL, MA, ME, MI, MN, NH, NY, VT, WI) reaching over 600,000 Medicare fee-for-service beneficiaries Duration of model test: January 2012 December 2014; 19 ACOs extended for 2 additional years Results from actuarial analysis 14

Independence at Home (IAH) Demonstration saves more than $3,000 per beneficiary IAH tests a service delivery and shared savings model using home-based primary care to improve health outcomes and reduce expenditures for highrisk Medicare beneficiaries In year 1, demo produced more than $25 million in savings, an average of $3,070 per participating beneficiary per year CMS will award incentive payments of $11.7 million to nine practices that produced savings and met the designated quality measures for the first year All 17 participating practices improved quality in at least three of the six quality measures There are 17 total practices, including 1 consortium, participating in the model Approximately 8,400 patients enrolled in the first year Duration of initial model test: 2012-2015 15

Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration has generated net savings Medicare participated in 8 state-led multi-payer patient centered medical home (PCMH) initiatives in partnership with Medicaid and commercial payers CMS supports these multi-payer PCMH initiatives through: Enhanced, non-visit-based payments to practices, community-based support teams, and states Quarterly data feedback Gross savings of $40.3 million and net savings of $4.2 million were observed Initially 8 states (ME, MI, MN, NC, NY, PA, RI, VT) encompassing more than 4,000 providers, 700 practices, and 350,000 Medicare fee-for-service beneficiaries participating in the first year Duration of initial model test: July 2011 December 2014 ME, MI, NY, RI, VT were extended through Dec 2016 16

Comprehensive Primary Care (CPC) is showing early positive results CMS convenes Medicaid and commercial payers to support primary care practice transformation through enhanced, non-visit-based payments, data feedback, and learning systems In program year 1 across all 7 regions, CPC reduced Medicare Part A and B expenditures per beneficiary by $14 or 2%* Reductions appear to be driven by initiative-wide impacts on hospitalizations, ED visits, and unplanned 30-day readmissions 7 regions (AR, OR, NJ, CO, OK, OH/KY, NY) encompassing 31 payers, nearly 500 practices, and approximately 2.5 million multi-payer patients Duration of model test: Oct 2012 Dec 2016 * Reductions relative to a matched comparison group and do not include the care management fees (~$20 pbpm) 18

Partnership for Patients contributes to quality improvements Data shows Leading Indicators, change from 2010 to 2013 Ventilator- Associated Pneumonia Early Elective Delivery Central Line- Associated Blood Stream Infections Venous thromboembolic complications Readmissions 62.4% 70.4% 12.3% 14.2% 7.3% 18

The CMS Innovation Center was created by the Affordable Care Act to develop, test, and implement new payment and delivery models The purpose of the [Center] is to test innovative payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care furnished to individuals under such titles Section 3021 of Affordable Care Act Three scenarios for success 1. Quality improves; cost neutral 2. Quality neutral; cost reduced 3. Quality improves; cost reduced (best case) If a model meets one of these three criteria and other statutory prerequisites, the statute allows the Secretary to expand the duration and scope of a model through rulemaking 19

The Innovation Center portfolio aligns with delivery system reform focus areas Focus Areas Pay Providers CMS Innovation Center Portfolio* Test and expand alternative payment models Accountable Care Pioneer ACO Model Medicare Shared Savings Program (housed in Center for Medicare) Advance Payment ACO Model Comprehensive ERSD Care Initiative Next Generation ACO Primary Care Transformation Comprehensive Primary Care Initiative (CPC) Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration Independence at Home Demonstration Graduate Nurse Education Demonstration Home Health Value Based Purchasing Medicare Care Choices Bundled payment models Bundled Payment for Care Improvement Models 1-4 Oncology Care Model Comprehensive Care for Joint Replacement (proposed) Initiatives Focused on the Medicaid Medicaid Incentives for Prevention of Chronic Diseases Strong Start Initiative Medicaid Innovation Accelerator Program Dual Eligible (Medicare-Medicaid Enrollees) Financial Alignment Initiative Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents Medicare Advantage (Part C) and Part D Medicare Advantage Value-Based Insurance Design model Part D Enhanced Medication Therapy Management Deliver Care Distribute Information Support providers and states to improve the delivery of care Learning and Diffusion State Innovation Models Initiative Partnership for Patients SIM Round 1 Transforming Clinical Practice SIM Round 2 Community-Based Care Transitions Maryland All-Payer Model Health Care Innovation Awards Million Hearts Cardiovascular Risk Reduction Model Increase information available for effective informed decision-making by consumers and providers Health Care Payment Learning and Action Network Information to providers in CMMI models Shared decision-making required by many models * Many CMMI programs test innovations across multiple focus areas 23

Next Generation ACO Model builds upon successes from Pioneer and MSSP ACOs Designed for ACOs that are experienced in coordinating care for populations of patients These ACOs will assume higher levels of financial risk and reward than the Pioneer or MSSP ACOS Model Principles Prospective attribution Financial model for longterm stability Reward quality The model will test how strong financial incentives for ACOs can improve health outcomes and reduce expenditures Greater opportunities to coordinate care (e.g., telehealth and skilled nursing facilities) More predictable financial targets Benefit enhancements that improve patient experience Protect freedom of choice Allow beneficiaries to choose alignment with ACO Smooth ACO cash flow and improved investment capabilities 25

Bundled Payments for Care Improvement is also growing rapidly The bundled payment model targets 48 conditions with a single payment for an episode of care Incentivizes providers to take accountability for both cost and quality of care Four Models - Model 1: Retrospective acute care hospital stay only - Model 2: Retrospective acute care hospital stay plus post-acute care - Model 3: Retrospective post-acute care only - Model 4: Acute care hospital stay only 360 Awardees and 1755 Episode Initiators in Phase 2 as of July 2015 Duration of model is scheduled for 3 years: Model 1: April 2013 to present Models 2, 3, 4: October 2013 to present * Current until July 2015 26

Oncology Care Model: new emphasis on specialty care 1.6 million people annually diagnosed with cancer; majority are over 65 years Major opportunity to improve care and reduce cost Model Objective: Provide beneficiaries with higher intensity coordination to improve quality and decrease cost Key features Implement 6 part practice transformation Create two part financial incentive with $160 pbpm, payment and performance based payment Institute robust quality measurement Engage multiple payers Practice Transformation 1.Patient navigation 2.Care plan with 13 components based on IOM Care Management Plan 3.24/7 access to clinician and real time access to medical records 4.Use of therapies consistent with national guidelines 5.Data driven continuous quality improvement 6.ONC certified electronic health record and stage 2 meaningful use by year 3 27

Proposed Comprehensive Care for Joint Replacement would test a bundled payment model across a broad cross section of hospitals The proposed model tests bundled payment of lower extremity joint replacement Payment model would apply to most Medicare LEJR procedures within select geographic areas with few exceptions Payment model would be implemented through rulemaking Participants would include Inpatient Prospective Payment System Hospitals in selected Metropolitan Statistical Areas (MSA) not participating in phase II of the Bundled Payment for Care Improvement model Participating areas were selected in a two-step randomization process MSAs were placed into five groups based on their historic LEJR episode payment and population size MSAs were then randomly selected within each group * Current until October 2015 28

Comprehensive ESRD Care will improve patient centered coordination of care ESRD patients represent 1% of Medicare beneficiaries but account for 8% of payments ESRD PPS accounts for approximately 33% of total cost of care for ESRD patient Opportunity exist to improve patient centered care that coordinates dialysis care with care outside of dialysis CEC model will improve care coordination through the creation of ESRD Seamless Care Organizations (ESCO) that will include dialysis providers, nephrologist, and other medical providers ESCOs can be formed by Medicare certified dialysis facilities, nephrologist, certain other Medicare enrolled providers and suppliers Care Model Improve care coordination Clinical and support services Data driven, population care management Enhance communication between providers Whole-patient care management EHR information exchange among providers Increase access to care After hours call-in line; extended business hours Enhanced convenience through on-site rounding 25

Medicare Advantage Value Based Insurance Design Model offers more flexibility to Medicare Advantage Plans Allows MA plans to structure enrollee cost-sharing and other health plan design elements to encourage enrollees to use clinical services that have the greatest potential to positively impact on enrollee health Will begin on January 1, 2017 and run for 5 years Plans in 7 states will be eligible to participate Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania, and Tennessee Eligible Medicare Advantage plans in these states, upon approval from CMS, can offer varied plan benefit design for enrollees who fall into certain clinical categories identified and defined by CMS Changes to benefit design made through this model may reduce cost-sharing and/or offer additional services to targeted enrollees 26

Part D Enhanced Medication Therapy Management (MTM) Model Enhanced MTM, when implemented correctly, can improve health care and outcomes for patients and has the potential to lower overall health costs The model will assess whether additional incentives and flexibilities to design and implement programs will achieve improving compliance with medication protocols reducing medication-related problems increasing patients knowledge of their medications improving communication among prescribers, pharmacists, caregivers and patients Will begin January 1, 2017 with a 5 year performance period CMS will test the model in 5 part D regions Region 7 (Virginia) Region 11 (Florida), Region 21 (Louisiana), Region 25 (Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota, Wyoming) Region 28 (Arizona). 27

Million Hearts Cardiovascular Disease Risk Reduction Model will reward population-level risk management Heart attacks and strokes are a leading cause of death and disability in the United States Prevention of cardiovascular disease can significantly reduce both CVD-related and all-cause mortality Participant responsibilities Systematic beneficiary risk calculation* and stratification Shared decision making and evidence-based risk modification Population health management strategies Reporting of risk score through certified data registry Eligible applicants General/family practice, internal medicine, geriatric medicine, multi-specialty care, nephrology, cardiology Private practices, community health centers, hospital-owned practices, hospital/physician organizations Payment Model Pay-for-outcomes approach Disease risk assessment payment - One time payment to risk stratify eligible beneficiary - $10 per beneficiary Care management payment - Monthly payment to support management, monitoring, and care of beneficiaries identified as high-risk - Amount varies based upon population-level risk reduction *Uses American College of Cardiology/American Heart Association (ACA/AUA) Atherosclerotic Cardiovascular Disease (ASCVD) 10-year pooled cohort risk calculator 32

Medicare Care Choices Model (MCCM) provides new options for hospice patients MCCM allows Medicare beneficiaries who qualify for hospice to receive palliative care services and curative care at the same time. Evidence from private market that can concurrent care can improve outcomes, patient and family experience, and lower costs. Services The following services are available 24 hours a day, 7 days a week Nursing MCCM is designed to Increase access to supportive care services provided by hospice; Improve quality of life and patient/family satisfaction; Inform new payment systems for the Medicare and Medicaid programs. Model characteristics Hospices receive $400 PBPM for providing services for 15 days or more per month 5 year model Model will be phased in over 2 years with participants randomly assigned to phase 1 or 2 Social work Hospice aide Hospice homemaker Volunteer services Chaplain services Bereavement services Nutritional support Respite care 29

State Innovation Model grants have been awarded in two rounds CMS is testing the ability of state governments to utilize policy and regulatory levers to accelerate health care transformation Primary objectives include Improving the quality of care delivered Improving population health Increasing cost efficiency and expand value-based payment Six round 1 model test states Eleven round 2 model test states Twenty one round 2 model design states 30

Round 1 states are testing and Round 2 states are designing and implementing comprehensive reform plans Round 1 States testing APMs Round 2 States designing interventions Arkansas Maine Patient centered medical Health Accountable homes homes care Episodes Near term CMMI objectives Establish project milestones and success metrics Support development of states stakeholder engagement plans Massachusetts Support development and refinement of operational plans Minnesota Oregon Vermont 31

Round 1 of the Health Care Innovation Awards tested a broad range of delivery system innovations Awards tested service delivery and payment models that improved quality and decreased cost in communities across the U.S. 107 projects awarded Ideas tested include - Enhancing primary care - Coordinating care across multiple settings - New types of health care workers - Improving decision making - Testing new service delivery technologies Approximately 575,000 Medicare, Medicaid, and CHIP beneficiaries served Projects were funded in all 50 states* Awards ranged from ~$1 M to $30 M * Darker colors on map represent more HCIA projects in that state 32

Round 2 of the Health Care Innovation Awards shared goals with Round 1 but focused on four themes 39 projects awarded Increase focus on four areas that have high likelihood of driving health care system transformation and delivering better outcomes 1. Reduce Medicare, Medicaid, and CHIP expenditure in outpatient and/or post-acute settings 2. Improve care for populations with specialized needs 3. Transform the financial and clinical models for specific types of providers and suppliers 4. Improve the health of populations 27 states and the District of Columbia* Awards ranged from ~$2 M to $24 M * Darker colors on map represent more HCIA projects in that state 33

Transforming Clinical Practice Initiative is designed to help clinicians achieve large-scale health transformation The model will support over 150,000 clinician practices over the next four years to improve on quality and enter alternative payment models Two network systems will be created Phases of Transformation 1) Practice Transformation Networks: peer-based learning networks designed to coach, mentor, and assist 2) Support and Alignment Networks: provides a system for workforce development utilizing professional associations and publicprivate partnerships 34

Alternative Payment Models (APMs) APMs are new approaches to paying for medical care through Medicare that incentivize quality and value. According to MACRA law, APMs include: CMS Innovation Center model (under section 1115A, other than a Health Care Innovation Award) MSSP (Medicare Shared Savings Program) Demonstration under the Health Care Quality Demonstration Program Demonstration required by Federal Law MACRA does not change how any particular APM rewards value. APM participants who are not QPs will receive favorable scoring under MIPS. Only some of these APMs will be eligible APMs. 35

How does MACRA provide additional rewards for participation in APMs? Most physicians and practitioners who participate in APMs will be subject to MIPS and will receive favorable scoring under the MIPS clinical practice improvement activities performance category. APM participants Those who participate in the most advanced APMs may be determined to be qualifying APM participants ( QPs ). As a result, QPs: 1. Are not subject to MIPS 2. Receive 5% lump sum bonus payments for years 2019-2024 3. Receive a higher fee schedule update for 2026 and onward QPs 36

What is an eligible APM? Eligible APMs are the most advanced APMs that meet the following criteria according to the MACRA law: Base payment on quality measures comparable to those in MIPS Require use of certified EHR technology Either (1) bear more than nominal financial risk for monetary losses OR (2) be a medical home model expanded under CMMI authority 37

How do I become a qualifying APM participant (QP)? QPs are physicians and practitioners who have a certain % of their patients or payments through an eligible APM. eligible APM QP Beginning in 2021, this threshold % may be reached through a combination of Medicare and other non-medicare payer arrangements, such as private payers and Medicaid. QPs: 1. Are not subject to MIPS 2. Receive 5% lump sum bonus payments for years 2019-2024 3. Receive a higher fee schedule update for 2026 and onward 38

Potential value-based financial rewards APMs and eligible APMs in particular offer greater potential risks and rewards than MIPS. In addition to those potential rewards, MACRA provides a bonus payment to providers committed to operating under the most advanced APMs. MIPS only MIPS adjustments APMs APM-specific rewards + MIPS adjustments eligible APMs eligible APMspecific rewards + 5% lump sum bonus 39

Recall: How MACRA get us closer to meeting HHS payment reform goals The Merit-based Incentive Payment System helps to link fee-for-service payments to quality and value. New HHS Goals: 2016 2018 The law also provides incentives for participation in Alternative Payment Models via the bonus payment for Qualifying APM Participants (QPs) and favorable scoring in MIPS for APM participants who are not QPs. 30% 85% 50% 90% All Medicare fee-for-service (FFS) payments (Categories 1-4) Medicare FFS payments linked to quality and value (Categories 2-4) Medicare payments linked to quality and value via APMs (Categories 3-4) Medicare payments to QPs in eligible APMs under MACRA 40

How will MACRA affect me? Am I in an eligible APM? Yes No Do I have enough payments or patients through my eligible APM? Yes No Am I in an APM? Yes No Is this my first year in Medicare OR am I below the low-volume threshold? Yes Not subject to MIPS No Subject to MIPS Qualifying APM Participant 5% lump sum bonus payment 2019-2024 Higher fee schedule updates 2026+ APM-specific rewards Excluded from MIPS Subject to MIPS Favorable MIPS scoring APM-specific rewards Bottom line: There are opportunities for financial incentives for participating in an APM, even if you don t become a QP.

How will physicians and practitioners be scored under MIPS? A single MIPS composite performance score will factor in performance in 4 weighted performance categories: MIPS Composite Performance Score Quality Resource use Clinical practice improvement activities Meaningful use of certified EHR technology 4

How much can MIPS adjust payments? Based on the MIPS composite performance score, physicians and practitioners will receive positive, negative, or neutral adjustments up to the percentages below. MIPS adjustments are budget neutral. A scaling factor may be applied to upward adjustments to make total upward and downward adjustments equal. MAXIMUM Adjustments 4% 5% 7% 9% -4% -5% -7% -9% 2019 2020 2021 2022 onward Merit-Based Incentive Payment System (MIPS) Adjustment to provider s base rate of Medicare Part B payment 4

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MACRA Goals Through MACRA, HHS aims to: Offer multiple pathways with varying levels of risk and reward for providers to tie more of their payments to value. Over time, expand the opportunities for a broad range of providers to participate in APMs. Minimize additional reporting burdens for APM participants. Promote understanding of each physician s or practitioner s status with respect to MIPS and/or APMs. Support multi-payer initiatives and the development of APMs in Medicaid, Medicare Advantage, and other payer arrangements. 45

Disclaimers This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. This presentation is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Medicare policy changes frequently, and links to the source documents have been provided within the document for your reference The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.. 46