Reflecting on Our Journey towards Health Equity

By: Dr. Cara James, Director of the CMS Office of Minority Health

Each April, in recognition of National Minority Health Month, we commemorate past achievements, acknowledge current efforts, and outline our continued journey towards health equity and equality for all. Fifty years ago, our journey included stops in Independence, Missouri where Medicare and Medicaid became law; in Selma and Montgomery, Alabama; and in Washington, D.C. for the signing of the Voting Rights Act and Civil Rights Act.

Since then, there have been many more landmark achievements in health equity. Events such as the publication of the Secretary’s report on Black & Minority Health (the Heckler Report) and the creation of the HHS Office of Minority Health illustrate the increased national attention on the need to address health and health care disparities. The publication of the Agency for Healthcare Research and Quality’s annual National Healthcare Quality and Disparities Report illustrates our commitment to track our progress. The passage of the Affordable Care Act and the enrollment of millions of Americans, including many people of color in health plans, illustrate our continued advancement towards better care and healthier communities.

Five years ago, the Affordable Care Act established three additional offices of minority health within six HHS agencies. While several HHS agencies already had offices of minority health, the Office of Minority Health (OMH) at the Centers for Medicare & Medicaid Services (CMS) was an office newly established through the Affordable Care Act. The principal aim for CMS is better care, healthier people, and smarter spending. To help achieve this aim, the CMS Office of Minority Health ensures that the voices and needs of minority and underserved populations are present in the development, implementation, and evaluation of CMS programs and services. We are dedicated to working on behalf of all CMS beneficiaries, while strategically focusing on racial and ethnic minorities, individuals with disabilities, and Lesbian, Gay, Bi sexual and Transgender (LGBT) minorities. CMS OMH activities include: From Coverage to Care, the CMS Equity Plan for Improving Quality in Medicare, strengthening CMS data collection and analysis, and working across the agency to embed a focus on health equity into new and existing programs and policies.

From Coverage to Care is an ongoing initiative designed to help consumers understand their healthcare coverage and how to access the care they need. Additionally, the CMS Equity Plan for Improving Quality in Medicare is CMS’ first strategic equity plan. Launched in 2015, this equity plan identifies six priorities and provides an action-oriented, results-driven approach for advancing health equity by improving the quality of care provided to racial and ethnic minority and other underserved Medicare beneficiaries. Last month, CMS OMH launched an interactive web based tool for mapping Medicare disparities. The Mapping Medicare Disparities Tool contains health outcome measures for disease prevalence, costs, and hospitalization for 18 specific chronic conditions, emergency department utilization, readmissions rates, mortality and preventable hospitalizations.

We know we cannot achieve health equity on our own. It will take the support of partners from the federal to the community level.  We encourage you to join us on the path to health equity by using the resources discussed in this blog, bookmarking the CMS OMH website, joining our listserv, and of course building on your own health equity activities!


Our Hopes for the Comprehensive Care for Joint Replacement Model

By Patrick Conway, CMS Principal Deputy Administrator and Chief Medical Officer

Today’s launch of the Comprehensive Care for Joint Replacement Model (CJR) is a major step toward transforming care delivery in Medicare. Why? Because this model looks to improve care and quality for the most common procedures that Medicare beneficiaries have, hip and knee replacements. In 2014, more than 400,000 Medicare beneficiaries received a hip or knee replacement, costing more than $7 billion for the hospitalizations alone. Despite the high volume of these surgeries, quality and costs of care for these hip and knee replacement surgeries still vary greatly among providers. For instance, the rate of complications, like infections or implant failures, after surgery can be more than three times higher for procedures performed at some hospitals than at others.

The model aligns with what matters to beneficiaries—better outcomes for a whole episode of care. The model includes patient-reported outcomes after surgery and incentivizes better care coordination. One beneficiary said it best when she described that what she cared about for her hip replacement was getting out of the hospital as quickly as possible without an infection or complication and then being able to go back to playing with her grandkids and gardening. The model incentivizes a system that aligns with her goals and the goals of so many beneficiaries.

We are excited about the CJR model’s potential to improve the quality and efficiency of care for Medicare beneficiaries, to contribute toward a health care system that delivers better care, spends our dollars more wisely, and leads to healthier Americans.

How will CJR work? About 800 hospitals located in 67 selected markets will be accountable for the costs and quality of related care from the time of the hip or knee replacement surgery through a post-hospitalization period. They will receive target prices for these joint replacement cases at the beginning of each year. The target price represents expected spending for lower joint replacement episodes, including the initial hospital stay for the procedure and 90 days after discharge from the hospital. If patients receive high quality care and spending is less than the target, a hospital may receive an additional payment from Medicare. If their spending is above the target, hospitals may be required to repay Medicare for a portion of the difference.

We expect this incentive to coordinate the services a patient receives before, during, and after surgery will encourage hospitals and clinicians to partner with nursing facilities, home health agencies and other providers of rehabilitation services to provide seamless, high quality care.

We want hospitals to be successful under this model because success means that Medicare’s beneficiaries will receive better quality care. In the run up to today’s launch, our staff individually contacted the program coordinators at all 800 hospitals to offer data and other resources to assist them on this multi-year journey. CMS will continue to collaborate with hospitals and their physicians and other clinicians to provide support and share best practices.

What will beneficiaries notice? First, beneficiaries will continue to choose their doctor, the hospital where they receive treatment, and the type and location of rehabilitation care they receive. If their hospital is a model participant, they will get a letter explaining the model. Patients whose chosen hospital participates in the model should experience improved care coordination. For instance, we expect that nursing facilities will understand a patient’s needs better before that patient is discharged from the hospital.

The CJR model offers a chance for hospitals, doctors, and other providers to partner with CMS in furthering our shared goal of improving the quality of care for beneficiaries undergoing the most common inpatient surgery, lower extremity joint replacements. The model is part of the Administration’s broader strategy to improve the health care system by paying providers for what works, unlocking health care data, and finding new ways to coordinate and integrate care to improve quality.

We are excited to begin this groundbreaking initiative and will work with hospitals, physicians, and other providers throughout the model to ensure they have the tools to succeed and improve upon what they do best: provide high quality, coordinated care to beneficiaries.

For more information about the CJR model, please visit:

Los Impuestos y la Cobertura de Salud: Cinco Consejos al Presentar la Declaración de Impuestos

31 de marzo de 2016
Por: Kevin Counihan, Director General de los Mercados de Seguros Médicos, Centros de Servicios de Medicare y Medicaid

El año pasado, millones de personas obtuvieron cobertura de salud de calidad y a su alcance económico a través del Mercado de Seguros Médicos, y la mayoría se beneficiaron de los pagos por adelantado del crédito tributario de prima para reducir el costo de sus primas/cuotas mensuales. Ya que solo quedan unas cuantas semanas para presentar los impuestos, es un buen momento para darles un recordatorio a los consumidores nuevos y los que renovaron  sobre lo que necesitan saber cuándo presenten sus impuestos.

Para aquellos que volvieron al Mercado de seguros en 2015 para renovar su cobertura o escoger otro plan, el proceso de declaración de impuestos es generalmente el mismo al año pasado. Pero, para las personas que se inscribieron por primera vez para la cobertura del Mercado en 2015 el proceso puede ser nuevo. Todos los consumidores del Mercado deberían haber recibido ya en el correo  el Formulario 1095-A. Este documento incluye información importante que se necesita para completar y presentar una declaración de impuestos.

Los consumidores del Mercado que recibieron los pagos adelantados del crédito tributario de prima están obligados a presentar una declaración de impuestos para reconciliar dicha ayuda financiera. Esto es similar al proceso de reconciliación de los impuestos retenidos de los salarios durante el año, los consumidores reciben un reembolso mayor o menor dependiendo de si los impuestos correspondientes se retuvieron en base a los ingresos reales del contribuyente de impuestos y otros factores.

Es extremadamente importante que los que recibieron pagos por adelantado del crédito tributario de prima reconcilien estos pagos cuando presenten su declaración de impuestos. Las personas que no lo hagan por lo general tendrán un retraso en sus reembolsos, y no serán elegibles para recibir los pagos adelantados del crédito tributario de prima en los próximos años.

Los individuos que tengan cobertura de salud del Mercado u otros tipos de seguro también pueden haber recibido otros formularios adicionales llamados Formulario 1095-B o C-1095 de parte de su empleador, compañía de seguros, o el programa de gobierno que proporciona su cobertura, como Medicare o Medicaid. Los contribuyentes no necesitan incluir esta información a su declaración de impuestos o esperar a recibir el formulario antes de llenar sus impuestos federales, pero la forma debe ser conservada en un lugar seguro con otros documentos importantes de sus impuestos.

Un recordatorio importante: Como la mayoría de los declarantes de impuestos utilizan un preparador de impuestos o el software de preparación de impuestos, la mayoría de los contribuyentes sólo tendrán que responder a las preguntas cuando se les solicite.

Estamos aquí para ayudar. Los consumidores del Mercado que tengan preguntas deben comunicarse con el Centro de Llamadas del Mercado (1-800-318-2596). Recursos adicionales e información también está disponible en o

A continuación, resumimos cinco consejos útiles para los consumidores del Mercado y otros declarantes de impuestos cuando se trata de la presentación de impuestos este año:

Cinco consejos para quienes presentan declaraciones de impuestos

  1. La mayoría de la gente sólo tiene que marcar una casilla: La gran mayoría de los declarantes de impuestos tienen una cobertura que califica (incluyendo la cobertura de un empleador, Medicare, Medicaid u otra cobertura) y sólo tendrán que marcar una casilla cuando presenten sus impuestos para indicar que cada una de las personas en su hogar tuvieron cobertura en el año 2015. Este año, muchos consumidores recibirán en el correo de parte de su empleador, compañía de seguros, o el programa de gobierno que proporciona su cobertura, como Medicare o Medicaid, un nuevo formulario llamado formulario 1095-B o un formulario 1095-C. Los contribuyentes no tienen que incluir esta información con su declaración de impuestos o esperar a recibir el formulario antes de llenar sus impuestos, pero si deben conservar este formulario en un lugar seguro con otros documentos relacionados con sus impuestos. Para obtener más información sobre todas estas formas, visite el sitio web del IRS:
  1. Los consumidores del Mercado deben presentar una declaración de impuestos para reconciliar cualquier pago anticipado del crédito tributario de prima que recibieron para poder mantener su elegibilidad para esta ayuda en el futuro: Todos los consumidores del Mercado deberían haber recibido ya en el correo el Formulario 1095-A. Este formulario incluye información importante que se necesita para completar y presentar una declaración de impuestos. Es extremadamente importante que los que recibieron pagos por adelantado del crédito tributario de prima reconcilien estos pagos cuando presenten su declaración de impuestos. Las personas que no lo hagan por lo general tendrán un retraso de su reembolso, y no podrán ser elegibles para el pago anticipado de los créditos tributarios de prima en los próximos años. 
  1. La multa por no tener cobertura aumentara. Para aquellos que podían costearse un seguro médico y optaron por no obtener la cobertura, la multa por no tener la cobertura mínima esencial en el año 2015 subió hasta un 2 por ciento de los ingresos familiares o $ 325 por persona. La multa se prorratea según el número de meses que una persona no está asegurada. La multa sube de nuevo en el año 2016. Si alguien no tiene cobertura o una exención en el año calendario 2016, pero podría pagar la cobertura, la tasa aumenta a $695 por persona o el 2,5% de los ingresos, lo que sea mayor. Para más información, visite
  1. Algunas personas que no tuvieron cobertura de salud en el año 2015 calificaran para una exención: Mientras que los que pueden costear la cobertura de salud pero optaron por no inscribirse por lo general tienen que pagar una multa, algunas personas que no pudieron pagar una cobertura o cumplen con otras condiciones específicas pueden recibir una exención. Usted puede encontrar más información en línea del Mercado o del IRS en oísicas-y-Familias. 
  1. Hay ayuda disponible. Si la gente tiene preguntas acerca de los formularios de impuestos del Mercado, como se califica para las exenciones, o la multa, deben ponerse en contacto con el Centro de Llamadas del Mercado. El centro de llamadas está abierto todo el día, todos los días llamando 1-800-318-2596. recursos adicionales e información también está disponible en o

The Marketplace Risk Adjustment Program: Promoting Access, Quality, and Choice for Consumers

By Kevin Counihan, CEO of the Health Insurance Marketplaces
Dr. Patrick Conway, CMS Acting Principal Deputy Administrator

This week, CMS brings together health care stakeholders and experts to discuss an esoteric sounding, yet important, topic: the individual and small group market risk adjustment programs created by the Affordable Care Act (ACA).  Risk adjustment is critical to making the ACA’s better-known market reforms work well for insurers and consumers. By reducing incentives for issuers to try to design products that attract a healthy risk pool, risk adjustment lets issuers compete on quality, price, and products that meet the needs of all consumers, protecting consumers’ access to a range of robust options.

Risk adjustment is a longstanding and important part of the Medicare Advantage and Medicare Prescription Drug Programs and has proven effective in making these programs work well for seniors.  Likewise, the ACA’s risk adjustment program is already delivering on its promise of affordable coverage that meets consumers’ needs. But, there is always room for improvement.

That’s why CMS recently released a white paper ( that evaluates our experience with the risk adjustment formula to date and analyzes possible changes. The white paper provides data and analysis about how the program has operated in the past, so that information, best practices, and ideas for improvement can be shared. And that’s why we’re bringing a broad range of stakeholders together to discuss these issues.

As we consider comments and feedback in our meeting on Thursday, March 31, on the future of the ACA’s risk adjustment program, we will keep in mind key principles to simultaneously make improvements while staying true to the goals of the program.

Promoting Access, Quality, and Choice for Consumers with Diverse Health Care Needs

Before the ACA, Americans with pre-existing medical conditions were often left out of the health insurance market. Now, because of the ACA, Americans with pre-existing condition can no longer be charged more or denied coverage just because they’ve been sick.

This means that insurance companies have had to adapt to a new way of working.  Instead of “medical underwriting” – a practice where an insurance company requires you to disclose your health status to determine whether to offer you coverage, at what price, and with what exclusions – insurance companies must offer you coverage regardless of your health status and can’t charge you more for being sick.

Risk adjustment is an essential part of making the individual and small group markets work well under a system where everyone, including people with pre-existing conditions, can buy high-quality coverage.

Through risk adjustment, insurance companies with sicker-than-average enrollees receive payments from other health insurance companies with healthier-than-average enrollees. That means that issuers make or lose money based on the characteristics of the products they offer, rather than how sick or healthy their enrollees are. This, in turn, lets issuers compete in the market by designing products that meet the needs of all consumers, rather than designing products to be unattractive to those who are sick.

For example, thanks to risk adjustment, it can make financial sense for issuers to develop specialized care management programs to meet the needs of people with chronic or other conditions. If such plans attract more expensive enrollees, issuers know they will be compensated by risk adjustment.

We are already seeing some Marketplace plans innovate in this area to meet the needs of consumers with challenging health issues, for example by offering plans that focus on diabetes management and other chronic illnesses. Risk adjustment may also help new or smaller businesses participate in the market without fear of attracting a large number of sick enrollees in any particular year.

Assessing the Marketplace Risk Adjustment Program

The risk adjustment methodology was designed with input from trade associations, insurance companies, actuaries, clinicians, economists, and other members of the public. It was implemented through rulemaking with a public notice and comment period. CMS worked closely with health insurance companies to ensure that the risk adjustment program uses the best available data. And all insurance companies – large and small, new or established – play by the same rules.

The first finding of the CMS white paper is that the risk adjustment program has largely worked as intended to date. For the 2014 benefit year, the formula successfully transferred $4.6 billion from issuers with healthier enrollees to issuers with sicker enrollees.  Our data and an outside independent analysis ( found that the main determinant of whether an issuer received a payment is the relative health of their enrollees, which is a sign of health for the program.

These analyses also show that the formula hasn’t favored large plans over small plans, or the reverse, indicating no bias by the size of the plan or insurance company. We expect performance of the program to improve with experience. Accurate risk adjustment payments depend on issuers accurately collecting, managing, and submitting data on their population’s health. While the ACA-compliant individual and small group markets are still relatively new, these core capabilities appear to have worked well in 2014 and we expect will contribute to successful health plan operation even in a market without risk adjustment.

What’s Next?

We have recently made and announced a number of changes to risk adjustment. In response to issuers’ requests for earlier information, we distributed risk adjustment data reports to insurance companies earlier this month to help them with setting their 2017 rates. These early reports rely on the information insurance companies report to CMS, and so they are only available in markets where sufficient issuers had submitted their data, and they are only as accurate as the data provided. This is why it is important that the companies focus on data management to fully and accurately report their experience and try to do so as early in the year as feasible.

We have also made some other adjustments to the methodology for the 2017 plan year including using more recent data, updating medical and drug trends, and incorporating preventive services into companies’ risk adjustment calculations.

As we contemplate making additional changes, we want to get more input from the public. And that’s the purpose of the public meeting on risk adjustment. As outlined in more detail in the white paper, some of the ideas we want to discuss include: whether and how to account for partial year enrollment in the model; whether and how to develop a prescription drug model, accounting for newer high-cost medications; whether and how to pool high risk enrollees; and whether and how to recalibrate the model based on data for the individual and small group populations, instead of a commercial dataset drawn from the employer market.

We look forwarding to hearing feedback from the public about these and other possible changes to the risk adjustment program.

We will continue to listen and learn to make sure we operate this vital program to maximum effect. We will take feedback and suggestions through April 22, 2016, and will keep the public informed as we consider proposals to change and improve the risk adjustment program in 2018 to serve the goals of providing affordable coverage and better care for millions of Americans.

CMS Invites Quality Innovation Network-Quality Improvement Organizations to Submit Special Innovation Projects to Expand Their Reach in Improving Care Delivery

By: Patrick Conway, MD, MSc
Acting Principal Deputy Administrator
Deputy Administrator for Innovation and Quality
CMS Chief Medical Officer

Kate Goodrich, MD MHS
Center for Clinical Standards and Quality

Jean Moody-Williams, RN, MPP
Deputy Director
Center for Clinical Standards and Quality

Dennis Wagner, MPA
Director, Quality Improvement and Innovation Group
Center for Clinical Standards and Quality

The Centers for Medicare & Medicaid Services’ (CMS) Quality Improvement Organization (QIO) Program is constantly evolving to help ensure that Medicare beneficiaries receive better care, better health, and greater value. Today, CMS is announcing the program’s next evolution: two projects focused on supporting and scaling quality improvement innovations.

With this announcement, Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) can collaborate with health care providers and/or partners to compete for 28 Special Innovation Project (SIP) awards that fall within two topic categories totaling $8 million.

SIPs are two-year quality improvement projects that align with the goals of the CMS Quality Strategy ( and emphasize the power of partnerships. There are two categories of SIPs for QIN-QIOs to consider:

  1. “Innovations that Advance Local Efforts for Better Care and Smarter Spending,” which will address healthcare quality issues that occur within specific QIN-QIO regions.
  1. “Interventions that are Ripe for Spread and Scalability,” which will focus on expanding the scope and national impact of a quality improvement project that has experienced proven but limited success. The expectation is that similar benefits would be experienced on a large scale if spread throughout the greater health care community.

The scalability category aligns with the CMS Strategic Innovation Engine (SIE) (, a new endeavor launched in August of 2015. The SIE is working to rapidly move innovative, evidence-based quality practices from research to implementation through the QIO Program. In consultation with the SIE Executive Leadership Council, CMS is seeking projects that:

  • Streamline patient flow in various health care settings, including hospital units, outpatient clinics, primary care offices, ambulatory surgical centers, and cancer centers resulting in efficiencies, improved satisfaction, decreased mortality, better care, healthier people, and smarter spending.
  • Work with health plans and/or care coordination providers to deploy an integrated approach to post-acute care that results in enhanced care management, safe transitions from one care setting to another, improved health outcomes, and reductions in harms.
  • Increase value, patient affordability, and appropriate use of specialty drugs by applying evidenced based criteria to prescribing practices and by monitoring effectiveness when providers have a choice(s) among equally effective drugs with differing costs.
  • Address acute pain management. For example, more is needed to assist sickle cell patients: from accurate identification of their illness to education of emergency department staff on sickle cell disease while addressing the cultural stigmas often associated with the disease.
  • Utilize big data analytics to reduce preventable harm in healthcare.

We encourage those in the larger healthcare community who are leading quality work in these areas, with interventions and proven results, to reach out and explore potential partnerships with QIN-QIOs. Through collaboration with healthcare providers, patients, families, and other key stakeholders, QIN-QIOs have tremendous potential to take those interventions to the national level and improve the health care delivery system by tapping into new settings of care and building upon the knowledge gained by people working on the front line of providing quality health care.

The QIN-QIOs selected to carry out these SIPs will leverage their data-driven approach, extensive partnerships, and the voices of patients and families to positively impact Medicare beneficiaries in their communities and nationwide.

The QIO Program’s 14 QIN-QIOs work with providers, community partners and beneficiaries on multiple data-driven quality improvement initiatives to improve patient safety, reduce harm, engage patients and families, improve clinical care and reduce healthcare disparities. For more information about the CMS QIO Program and for a complete list of QIN-QIOs, please visit the QIO Program website (

Taxes and Health Care Coverage: Five Tips for Tax Filers

By: Kevin Counihan, CEO of the Health Insurance Marketplaces, Centers for Medicare and Medicaid Services

Last year, millions of people purchased quality, affordable coverage through the Health Insurance Marketplace, and most benefitted from advance payments of the premium tax credit that lowered their monthly premiums. With the tax filing deadline a few weeks away, it’s a good time to remind everyone – both new and renewing consumers – about what they need to know when they file their taxes.

For those who returned to the Marketplace in 2015 to renew coverage or pick a different plan, the tax filing process is generally the same as last year. But, for the millions who signed up for Marketplace coverage in 2015 for the first time, the process may be a new one. By now, all Marketplace consumers should have received a statement in the mail from the Marketplace called a Form 1095-A. These statements include important information needed to complete and file a tax return.

Marketplace consumers who received advance payments of the premium tax credit are required to file a tax return to reconcile that financial assistance. This is similar to the reconciliation process for taxes withheld from wages during the year – consumers receive a larger or smaller refund depending on whether the appropriate taxes were withheld based on the tax filer’s actual income and other factors.

It’s extremely important that those who received advance payments of the premium tax credit reconcile these payments when they file their tax return. Individuals who do not do so will generally see their refunds delayed, and are not eligible to receive advance payments of the premium tax credit in future years.

Individuals with Marketplace or other types of health coverage may also have received additional forms called a Form 1095-B or 1095-C from their employer, insurance company, or the government program that provides their coverage, like Medicare or Medicaid. Taxpayers don’t need to attach this information to their return or wait to receive the form before filling their federal taxes, but should keep it in a safe place with other tax records.

An important reminder: Since most tax filers use a tax preparer or tax preparation software, most filers just need to answer questions when prompted.

We are here to help. Marketplace consumers having questions should contact the Marketplace Call Center (1-800-318-2596).  Additional resources and information for is also available at or

Here’s summary of five helpful tips for both Marketplace consumers and other tax filers when it comes to filing taxes this year:

Five Tips for Tax Filers

  1. Most people just need to check a box: The vast majority of tax filers have qualifying coverage (including employer coverage, Medicare, Medicaid, or other coverage) and will just need to check a box when they file their taxes to indicate that that everyone in their household had coverage for 2015. This year, many consumers will receive a new form called a Form 1095-B or a Form 1095-C in the mail from their employer, insurance company, or the government program that provides their coverage, like Medicare or Medicaid. Taxpayers don’t need to attach this information to their return or wait to receive the form before filling their taxes, but should keep it in a safe place with other tax records. For more information on all these forms, visit the IRS website at:
  1. Marketplace consumers must file a tax return to reconcile any advance payment of the premium tax credit they received in order to maintain eligibility for future help: By now, all Marketplace consumers should have received a statement in the mail from the Marketplace called a Form 1095-A. These statements include important information needed to complete and file a tax return. It’s extremely important that those who received advance payments of the premium tax credit reconcile these payments when they file their tax return. Individuals who do not do so will generally see their refunds delayed, and are not eligible for advance payment of premium tax credits in future years.
  1. The fee for not having coverage is increasing. For those who could afford health insurance and chose not to get coverage, the fee for not having minimum essential coverage in 2015 has increased to 2 percent of household income or $325 per person. The fee is pro-rated based on how many months a person is uninsured. The fee goes up again for 2016. If someone doesn’t have coverage or an exemption in the 2016 calendar year, but could afford coverage, the fee increases to $695 per person or 2.5% of income, whichever is higher.
  1. Some people who didn’t have health coverage in 2015 will qualify for an exemption: While those who can afford health coverage but chose not to enroll generally have to pay a fee, some people who couldn’t afford coverage or met other conditions can receive an exemption. You can find out more information online from the Marketplace or IRS at or
  1. Help is available. If people have questions about Marketplace tax forms, qualifying for exemptions, or the fee, they should contact the Marketplace Call Center. The call center is open all day, every day at 1-800-318-2596. Additional resources and information for is also available at or


CMS Strong Start for Mothers and Newborns Strategy II Initiative Second Annual Evaluation Report

By Patrick Conway, M.D., CMS Principal Deputy Administrator and Chief Medical Officer

Today, we at the Centers for Medicare & Medicaid Services (CMS) are pleased to announce findings from the second annual evaluation report for the Strong Start for Mothers and Newborns Strategy II Initiative. As noted with the release of our first annual report, Strong Start Strategy II seeks to build on work conducted by the Partnership for Patients and Strong Start Strategy I to improve newborn health through a reduction in early elective deliveries. Babies are generally healthier and have better long-range outcomes when they are born full-term.  Strategy I contributed to a 64.5% nationwide drop in early elective deliveries from 2010 to 2013.

The Strong Start II (hereafter referred to as Strong Start) builds on this success through prenatal care enhancements addressing the psychosocial needs of pregnant women eligible for Medicaid and CHIP.  Strong Start is an important federal initiative geared toward testing innovative approaches to improve maternal and infant health outcomes in low-income families.

Research consistently shows that infants born preterm (before 37 completed weeks of gestation) have higher mortality risks and may endure a lifetime of developmental and health problems when compared to their counterparts born after 37 weeks’ gestation.

Prenatal care enhancements provided through Strong Start are designed to promote overall maternal and infant health and particularly to reduce incidence of preterm birth and low birth weight.  The second annual report presents the progress Strategy II has made since its inception.

Strong Start has continued its partnership with 27 organizations representing nearly 200 provider sites in 32 states, Washington, D.C., and Puerto Rico.  The program continues to provide enhanced services through three approaches:

  • Group Care – Group prenatal care that incorporates peer-to-peer support in a facilitated setting for three components: health assessment, education, and support.
  • Birth Centers – Comprehensive prenatal care facilitated by midwives and teams of health professionals, including peer counselors and doulas.
  • Maternity Care Homes – Enhanced prenatal care at traditional prenatal sites with enhanced continuity of care and expanded access to care coordination, education, and other services.

Enrollment increased dramatically in the second year of program operations, with a total of 23,000 women enrolled from March 2013 to the end of the first calendar quarter of 2015. Enrollment is expected to continue to grow to more than 40,000 participants by the program’s end in February 2017.  Additionally, participants continue to express overwhelming satisfaction, with 90% stating that they were either very satisfied or extremely satisfied with their prenatal care.

In addition to their standard schedule of prenatal care visits, Strong Start participants receive enhanced care visits in accordance with their psychosocial needs.  Enhanced visits provide services such as care coordination, referrals to local resources, prenatal health education, and peer support.

Upon enrollment, Strong Start participants have several risk factors, including many pertaining to psychosocial needs:

  • Depression upon enrollment (nearly a quarter of participants report being depressed at intake)
  • Unstable housing
  • Unemployment
  • Unmet mental health and dental needs
  • Food insecurity
  • Unmarried or unpartnered status

Results from the second year evaluation indicate that, as was found in the first year, Strong Start participants have:

  • Lower rates of cesarean section than national averages, though there is wide variation among and within models
  • Higher rates of breastfeeding than national averages among similar populations

In addition, the new report finds that Strong Start participants have:

  • Overall preterm birth rates similar to national averages despite the high-risk population served
  • Lower preterm birth rates than national averages within racial-ethnic groups (Black , White, Hispanic)
  • Vaginal birth after cesarean rates that are nearly twice the national average

Although findings must be interpreted with caution because they are descriptive, we are pleased with what we have found thus far. Substantial progress was made during the second evaluation year in developing resources, particularly obtaining state Medicaid claims linked to vital records, which will enable development of a control group and an analysis of costs.  The third annual report is anticipated to contain analysis of further participant-level data, case studies based on site visits, and an initial analysis of linked data from states.

Much work remains to be done to reduce significant risks and complications for pregnant women and infants, but these early results from the Strong Start evaluation show promise for improving pregnancy outcomes.  We remain committed to working together to deliver higher quality care, smarter spending, and better health outcomes for low-income pregnant women and their newborns.

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