Accountable Health Communities (AHC)

Centers for Medicare & Medicaid Services (CMS) 

DEADLINE: Application Due Date: March 31, 2016 (1:00 p.m. ET) 

Letter of Intent to Apply Due Date: February 8, 2016

AWARD: Increase Awareness (Track 1): Up to $12 million total with individual awards of up to $1 million for a renewable one year contract. 
Provide Assistance (Track 2): Up to $30.84 million total with individual awards of up to $2.57 million for a renewable one year contract. 
Align Partners (Track 3): Up to $90.20 million total with individual awards of up to $4.51 million for a renewable one year contract.

NUMBER OF AWARDS: Increase Awareness (Track 1): 12 Cooperative Agreements
Provide Assistance (Track 2): 12 Cooperative Agreements
Align Partners (Track 3): 20 Cooperative Agreements

ELIGIBILITY: Community-based organizations, health care practices, hospitals and health systems, institutions of higher education, local government entities, tribal organizations, and for-profit and non-for-profit local and national entities with the capacity to develop and maintain relationships with clinical delivery sites and community service providers. 

TARGET POPULATION: Community-dwelling Medicare and Medicaid beneficiaries for all ages (children and adults), including those who are dually eligible. 

SUMMARY: The Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (CMMI) will assess whether systematically identifying the health-related social needs of community-dwelling Medicare and Medicaid beneficiaries, including those who are dually eligible, and addressing their identified needs, impacts those community-dwelling beneficiaries’ total health care costs and their inpatient and outpatient health care utilization. The Accountable Health Communities (AHC) model addresses a gap in the current delivery system by funding interventions that connect community-dwelling beneficiaries with community services. The AHC model will test three community-focused interventions of varying intensity and their ability to impact total health care costs and inpatient and outpatient health care utilization. This model will engage community-dwelling Medicare and Medicaid beneficiaries of all ages (children and adults). 

The model design was informed by an assessment of current CMS models and programs, including ACOs, Medicaid Managed Care, Medicaid health homes, and HCBS programs. Additionally it was informed by a growing evidence base of promising service delivery models that integrate community services into the clinical setting. Evidence supporting the AHC model falls into two categories: (1) evaluations of the health effects of community services that address specific health-related social needs (e.g., housing problems, food insecurity); and (2) evaluations of approaches to link patients with community services.

  • Track 1 Awareness – Increase beneficiary awareness of available community services through information dissemination and referral.
  • Track 2 Assistance – Provide community service navigation services to assist high-risk beneficiaries with accessing services.
  • Track 3 Alignment – Encourage partner alignment to ensure that community services are available and responsive to the needs of beneficiaries.

Each of these tracks requires the award recipient to serve as a hub responsible for coordinating efforts to: (1) identify and partner with clinical delivery sites (CDS) (e.g., clinics, hospitals); (2) conduct systematic health-related social needs screenings and make referrals; (3) coordinate and connect community-dwelling beneficiaries who screen positive for certain unmet health-related social needs and who are randomized to the intervention group to community service providers that might be able to address those needs; and (4) [Track 3 only] align model partners to optimize community capacity to address health-related social needs. 

CMS funds for this model cannot pay directly or indirectly for any community services (e.g., housing, food, violence intervention programs, and transportation) received by community-dwelling beneficiaries as a result of their participation in any of the three intervention tracks. Award recipients, however, must use their award monies to fund interventions intended to connect community-dwelling beneficiaries with those offering such community services. 

LINK to RFP:, CDFA # 93.650.