Beneficiary and Provider Overlaps in CMS Innovation Center Models

What Happens When Participants or Beneficiaries Are in More Than One CMS Innovation Center Model?

The CMS Innovation Center tests value-based care models involving different provider types, diseases/conditions, and geographies designed to lower health care costs, improve patient care, and support better health.

Sometimes, a provider may take part in more than one model, or a beneficiary may receive care from providers associated with different models. This can result in an “overlap.”

Some overlaps may be beneficial. However, since overlaps can complicate how CMS pays providers, collects data, and evaluates the initiatives, CMS has specific policies for determining which overlaps are allowed and managing these cases.

Criteria for Participant Provider Overlaps

Participant provider overlaps may be opportunities for providers to take part in complementary coordinated care initiatives. To accommodate this type of overlap, CMS must first ensure that an overlap will not:

• Affect evaluation of the initiatives or create conflicts with financial accountability. For instance, CMS must ensure that a provider’s participation in multiple initiatives will not result in that provider receiving duplicate incentive payments or repayments of losses for the same beneficiary.
• Violate statutory requirements. For example, CMS does not allow service providers and suppliers to participate in an accountable care organization under the Medicare Shared Savings Program if the service provider or supplier participates in any Innovation Center model, program, or demonstration project that involves Medicare shared savings.

Criteria for Beneficiary Overlaps

A beneficiary overlap occurs when a beneficiary is aligned or assigned to participants in two or more CMS Innovation Center models.

CMS applies the following principles when determining whether a beneficiary can overlap between initiatives. A beneficiary overlap must:

• Occur between two compatible initiatives that create synergy, not competition, and will not create unnecessary confusion for beneficiaries
• Ensure operational feasibility and uphold the initiative’s ability to be evaluated properly
• Avoid double payment of shared savings or other incentive payments
• Avoid multiple provider obligations for losses for the same beneficiary

To avoid duplicate payments, beneficiaries are typically assigned (aligned) to only one shared savings initiative; however, they are allowed to overlap across other types of initiatives if there are ways to account for the overlap.

IMPORTANT NOTE: Beneficiary alignment does not prohibit patients from seeing other providers in other models; however, those other providers cannot count or report non-aligned patients as part of the model.

Determining Beneficiary Alignment

A beneficiary may become aligned to a provider either when CMS announces a new model or initiative, or when the beneficiary’s current provider begins participating in a model already in operation. A beneficiary’s alignment to a provider or initiative may change over time, contributing to the need for careful consideration of overlaps.

CMS resolves overlap issues using the following principles to determine which model to prioritize for beneficiary alignment. All these factors are considered in the alignment decision but may be prioritized differently depending on the model.

• Beneficiary choice – Respect beneficiary choice to voluntarily align to a participating provider, when possible. For example, if given the option, a patient chooses to align to their primary care provider who is part of XYZ accountable care organization (ACO) in a model, the patient could not be aligned to any provider in another ACO in that model or any other model. However, the patient could continue to see the providers in the other ACOs or models.   
• Beneficiary health care needs – Align beneficiaries to participating providers who most specifically address their greatest health care needs. For example, a beneficiary with kidney disease might be aligned to their nephrologist in a kidney model over their primary care doctor in another type of model.
• Model performance year – Prioritize alignment before the start of an initiative or in an earlier performance year to maximize time in the initiative. For example, a model that has not yet started would likely get priority over a model in its last performance year.
• Evaluability – Ensure CMS Innovation Center models have enough beneficiaries assigned or aligned to successfully evaluate model impact and that model alignment is clearly identified. For example, a model with a low number of beneficiaries might get priority over a model with large numbers of beneficiaries to ensure it can be properly evaluated.
• Risk-based arrangement – To protect federal taxpayers, models with a two-sided financial risk arrangement will be prioritized over models with only upside risk.
• Integration of Medicare and Medicaid, where applicable – Beneficiaries with both Medicare and Medicare receive priority alignment to initiatives that will best support their dual status and focus on integrating the two programs. For example, the patient would be aligned to a model that works with both Medicare and Medicaid over a model just focused on Medicare.

Read more about the CMS Innovation Center’s models and initiatives

Originally posted on: September 11, 2025