Certification and Expansion

The evaluation questions in this course are not just academic. Federal law attaches a specific consequence to one of them: a CMMI model that is shown to work can be expanded nationwide without new legislation. Understanding that bar, and how rarely it is met, is the institutional version of “did it work.”

The certification standard

The authority that created CMMI (Section 1115A of the Social Security Act, from the intro course) lets the Secretary of Health and Human Services expand a model nationally, but only if strict conditions are met:

• The CMS Chief Actuary certifies that the model would reduce (or not increase) net Medicare spending, or the Secretary determines it would improve quality without increasing spending; and
• Expansion would not deny or limit coverage or benefits.

The actuarial certification is the load-bearing part. It is an independent, quantitative judgment that the model actually saves money net, exactly the gross-versus-net test from the previous module, applied as a legal standard.

Worth remembering: certification is the closest thing the system has to an official verdict that a model worked. It is deliberately hard: it requires net savings verified by an independent actuary, not a favorable press release or a promising pilot. That difficulty is a feature, because the whole point of this course is that most favorable-looking results do not survive rigorous scrutiny.

Why so few clear it

Of roughly 70 models tested, only about four have been certified for national expansion. The Pioneer ACO model from the case-studies module was the first, certified in 2015. The scarcity is not bureaucratic obstruction; it is the evaluation reality of this course made official. When you apply a rigorous, net-savings, independently-verified standard, most models simply do not meet it, for all the reasons the earlier modules laid out.

What certification tells a reader

When a model has been certified for expansion, that is strong evidence, an independent actuary has vouched for net savings. When a model has not, its favorable evaluations should be read with everything this course has taught: which number, which comparison, which population, gross or net. Certification is a useful sorting signal: it separates the handful of models that cleared the highest bar from the many that produced encouraging but unconfirmed results.

Key takeaways

• Federal law lets CMMI expand a model nationally only if the CMS Chief Actuary certifies net savings (or quality gains at no added cost) without limiting coverage.
• The standard is deliberately hard, and only about four of roughly 70 models have met it.
• Certification is the system’s most rigorous “it worked” signal; treat uncertified favorable results with the skepticism this course teaches.

Sources

• Congressional Budget Office, Federal Budgetary Effects of the Activities of the Center for Medicare and Medicaid Innovation (September 2023) (opens in a new tab)
• CMS Office of the Actuary, Certification of Pioneer ACO Model Savings (2015) (opens in a new tab)