The Players

Federal rulemaking is a play with a fixed cast. Each institution has a distinct role, and knowing who does what lets you follow a model from idea to implementation and understand where influence can be applied. This lesson introduces the players.

The executive branch

• CMS and the Innovation Center (CMMI). CMS runs Medicare and Medicaid; CMMI, inside it, designs, tests, and operates the models. This is where models are born and run.
• HHS and the Secretary. The Department of Health and Human Services is CMS’s parent; the Secretary holds the legal authorities that CMS exercises, including the 1115A powers.
• OMB and OIRA. The Office of Management and Budget, through its regulatory review office (OIRA), reviews significant proposed and final rules before they are published, a checkpoint every major rule passes through.

The scorekeepers and advisors

• The Congressional Budget Office (CBO). CBO independently estimates the budgetary effects of programs and legislation. Its scoring of CMMI, not CMMI’s own, is the authoritative fiscal picture the evaluation course drew on.
• MedPAC. The Medicare Payment Advisory Commission advises Congress on Medicare, issuing recommendations twice a year on how Medicare pays plans and providers.
• MACPAC. The Medicaid and CHIP Payment and Access Commission plays the parallel role for Medicaid and CHIP, and consults with MedPAC on people dually eligible for both programs.

Worth remembering: MedPAC and MACPAC do not make rules; they advise. But their analysis and recommendations shape the debate, inform Congress, and are cited throughout rulemaking, which is why so much of this curriculum’s evidence came from them. They are influential precisely because they are independent and nonpartisan, the same posture this institute aims for.

Congress and the public

• Congress. Writes the statute, can mandate or block models, funds the agencies, and conducts oversight. CMMI operates within the space Congress created.
• The public and stakeholders. Providers, plans, patient groups, trade associations, researchers, and individuals who comment on rules, advocate, and supply the real-world evidence agencies weigh. This is where you come in, and where Module 4 focuses.

Following the action

With the cast in mind, a model’s life becomes legible: CMMI designs it, OMB reviews the rule, CBO scores it, MedPAC or MACPAC weighs in, the public comments, and Congress watches and can intervene. Each later module follows this cast through a specific phase of the process.

Key takeaways

• The executive players (CMS/CMMI, HHS, OMB/OIRA) design, hold authority for, and review models and rules.
• The scorekeepers and advisors (CBO, MedPAC, MACPAC) independently estimate budget effects and advise Congress, shaping the debate without making rules.
• Congress writes and can change the underlying law, and the public participates through comment and advocacy.