Participation Agreement

Value in Treatment
Participation Agreement
Amendment to Section VI and Appendix B
2022 Amendment No. 1
CMS is unilaterally amending the Value in Treatment Participation Agreement (the
"Agreement") between _____________________________________________
("Participant") and the Centers for Medicare & Medicaid Services ("CMS") to
implement recent changes in the law related to budget sequestration.
CMS is authorized pursuant to Section XVI.D of the Agreement to amend the Agreement or
any Appendix thereto without the consent of the Participant as necessary to comply with
applicable federal or State law, regulatory requirements, accreditation standards or licensing
guidelines or rules.
CMS is unilaterally amending the Agreement to comply with recent changes in federal law. The
Protecting Medicare and American Farmers from Sequester Cuts Act (P.L. 117-71), enacted on
December 10, 2021, extended the temporary suspension of Medicare sequestration that was first
enacted from May 1, 2020 through December 31, 2020 under section 3709 of the Coronavirus
Aid, Relief, and Economic Security Act, then extended through March 31, 2021 under section
102 of Division N of the Consolidated Appropriations Act, 2021, and then extended again
through December 31, 2021 under section 1 of H.R. 1868 – To Prevent Across-the-Board Direct
Spending Cuts, and for Other Purposes. Under section 2 of the Protecting Medicare and
American Farmers from Sequester Cuts Act, the temporary suspension of Medicare sequestration
is further extended through March 31, 2022. Section 2 also states that for the period April 1,
2022 through June 30, 2022, Medicare sequestration will be set to 1%, and that starting on July
1, 2022, Medicare sequestration will be set to 2%.
To implement these changes in federal law, CMS is amending the Agreement to apply
sequestration to the Performance-Based Incentive Payments (“PBIP”) and to permit CMS to
apply a sequestration percentage reduction in an amount other than 2% to any PBIP or care
management fee (“CMF”) payments made to the Participant during the period of April 1, 2022
through June 30, 2022.
In light of the foregoing, CMS amends the Agreement as follows:
1. Application of Sequestration to the PBIP. Section VI.D.2 of the Agreement is

hereby amended in its entirety to read as follows:

2. CMS will calculate the amount of the Participant’s PBIP, if any, for the
Performance Year based on the total amount withheld from the CMF payments
made to the Participant for the Performance Year, in accordance with
SectionVI.B.2 and Appendix B, reduced by any applicable Medicare sequestration
percentage reduction.

2. Calculation of CMF Payments with Quality Withhold & Medicare
Sequestration Adjustment. Section III.B of Appendix B of the Agreement is
hereby amended in its entirety to read as follows:
B. Calculation of CMF Payments with Quality Withhold & Medicare Sequestration
Adjustment. The CMF payment made to the Participant is subject to a PBIP quality
withhold (No withhold in PY1; 5% in PY2; 10% in each Performance Year thereafter)
and, if a sequestration order is in effect, an adjustment to account for sequestration.
Specifically, the amount of the CMF for each ViT Code claim submitted for the
calendar quarter in which OUD Treatment Services were furnished to a
Participating Beneficiary under ViT is calculated as $125 per Participating
Beneficiary per month, minus the applicable PBIP quality withhold and any
applicable Medicare sequestration adjustments. This adjusted amount is then
multiplied by three to reflect the three-month duration of the calendar quarter. The
calculation formulas applicable to each Performance Year are reflected below.
Performance Year 1 (2021)
CMF per Participating Beneficiary per Month (PBPM)=$125 – [10%
withhold ($125 ))+(2% sequestration rate ((90%($125)))]=$125-[($12.50)
+($2.25)]=$110.25 PBPM
𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷)
= 𝐶𝐶𝐶𝐶𝐶𝐶 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 ∗ 3 𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚ℎ𝑠𝑠 = $𝟑𝟑𝟑𝟑𝟑𝟑. 𝟎𝟎𝟎𝟎 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃

*Note that the calculation above uses 0% as the sequestration rate because
budget sequestration was suspended for the duration of Performance Year 1
(2021).
Performance Year 2 (2022)

𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷) =
$125 – [(5% 𝑤𝑤𝑤𝑤𝑤𝑤ℎℎ𝑜𝑜𝑜𝑜𝑜𝑜 ($125 )) +
(2% 𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠 𝑟𝑟𝑟𝑟𝑟𝑟𝑟𝑟 ( (95%($125) ))] = $125 − [($6.25) +
($2.38)] = $𝟏𝟏𝟏𝟏𝟏𝟏. 𝟑𝟑𝟑𝟑 PBPM

𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝒆𝒆𝒏𝒏𝒏𝒏𝒏𝒏𝒏𝒏𝒏𝒏𝒏𝒏𝒏𝒏𝒏𝒏𝒏𝒏 𝒑𝒑𝒑𝒑𝒑𝒑 𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷)
= 𝐶𝐶𝐶𝐶𝐶𝐶 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 ∗ 3 𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚ℎ𝑠𝑠 = $𝟑𝟑𝟑𝟑𝟑𝟑. 𝟏𝟏𝟏𝟏 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃

*Note that the calculation above is an example using 2% as the sequestration
percentage reduction. A sequestration payment reduction is applied only if
sequestration is in effect for the period in which the payment is made, and the
sequestration percentage reduction may vary according to federal law.

Performance Year 3 to 4 (2023 to 2024)
𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝒏𝒏𝒏𝒏𝒏𝒏𝒏𝒏𝒏𝒏𝒏𝒏𝒏𝒏𝒏𝒏𝒏𝒏 𝒑𝒑𝒑𝒑𝒑𝒑 𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷) =
$125 – [(10% withhold($125 )) +
(2% sequestration rate((90%($125)))] = $125 − [($12.50) +
($2.25)] = $𝟏10.25 PBPM

𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸 (𝑷𝑷𝑩𝑩𝑩𝑩𝑩𝑩)
= 𝐶𝐶𝐶𝐶𝐶𝐶 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 ∗ 3 𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚ℎ𝑠𝑠 = $𝟑𝟑𝟑𝟑𝟑𝟑. 𝟕𝟕𝟕𝟕 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃

*Note that the calculation above is an example using 2% as the sequestration

Performance-Based Incentive Payments (PBIP)
Quality
Formula and Specific Amount Withheld
Performance Withhold
Year
(%)
PY 1 (2021)
Zero
𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷) 𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾
= 0 𝑤𝑤𝑤𝑤𝑤𝑤ℎℎ𝑜𝑜𝑜𝑜𝑜𝑜 ∗ $125 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 = $𝟎𝟎
PY 2 (2022)

PY 3 (2023)

PY 4 (2024)

5%

10%

10%

𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷) 𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾
= 𝐶𝐶𝐶𝐶𝐶𝐶 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 ∗ 3 𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚ℎ𝑠𝑠 = $𝟎𝟎
𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷) 𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾
= 5% 𝑤𝑤𝑤𝑤𝑤𝑤ℎℎ𝑜𝑜𝑜𝑜𝑜𝑜 ∗ $125 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 = $𝟔𝟔. 𝟐𝟐𝟐𝟐 − ($𝟔𝟔. 𝟐𝟐𝟐𝟐 ∗ 𝟎𝟎. 𝟎𝟎𝟎𝟎)
= $𝟔𝟔. 𝟏𝟏𝟏𝟏

𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑸𝑸𝑸𝑸𝑸𝑸𝒓𝒓𝒕𝒕𝒕𝒕𝒕𝒕 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷) 𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾
= 𝐶𝐶𝐶𝐶𝐶𝐶 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 ∗ 3 𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚ℎ𝑠𝑠 = $𝟏𝟏𝟏𝟏. 𝟑𝟑𝟑𝟑
𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷) 𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾 =
10% 𝑤𝑤𝑤𝑤𝑤𝑤ℎℎ𝑜𝑜𝑜𝑜𝑜𝑜 ∗ $125 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 = $𝟏𝟏𝟏𝟏. 𝟓𝟓𝟓𝟓 – (12.50 * 0.02) = $12.25
𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷) 𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾
= 𝐶𝐶𝐶𝐶𝐶𝐶 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 ∗ 3 𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚ℎ𝑠𝑠 = $𝟑𝟑𝟑𝟑. 𝟕𝟕𝟕𝟕
𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷) 𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾 =
10% 𝑤𝑤𝑤𝑤𝑤𝑤ℎℎ𝑜𝑜𝑜𝑜𝑜𝑜 ∗ $125 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 = $𝟏𝟏𝟏𝟏. 𝟓𝟓𝟓𝟓 – (12.50 * 0.02) = $12.25

𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝒓𝒓𝒓𝒓 𝒑𝒑𝒑𝒑𝒑𝒑 𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷) 𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾
= 𝐶𝐶𝐶𝐶𝐶𝐶 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 ∗ 3 𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚ℎ𝑠𝑠 = $𝟑𝟑𝟑𝟑. 𝟕𝟕𝟕𝟕
*Note that the calculation above is an example using 2% as the sequestration
percentage reduction. A sequestration payment reduction is applied only if
sequestration is in effect for the period in which the payment is made, and the
sequestration percentage reduction may vary according to federal law.
3. Application of the Sequestration to the PBIP. The second sentence of Section
IV of Appendix B of the Agreement is hereby revised in its entirety to read as follows:
“The Participant may earn back the PBIP quality withhold, reduced by the applicable

sequestration percentage reduction (if sequestration is in effect at the time the
payment is made), in the form of a PBIP if the Participant meets or exceeds the
applicable performance threshold.”
4. PBIP Quality Withhold Calculation. Section IV.A of Appendix B of the
Agreement is hereby revised by adding the following sentence after the first
sentence:
“These PBIP rates are subject to sequestration, if sequestration is in effect at the
time the payment is made.”
5. PBIP Quality Withhold Amount. Table 2 of Appendix B is hereby amended in its
entirety to read as follows:
Table 2: Performance-Based Incentive Payments (PBIP) Quality Withhold Amount
*Note that the calculation above is an example using 2% as the sequestration
percentage reduction. A sequestration payment reduction is applied only if
sequestration is in effect for the period in which the payment is made, and the
sequestration percentage reduction may vary according to federal law.
6. Effect of Amendment. All other terms and conditions of the Agreement shall
remain in full force and effect. In the event of any inconsistency between the
provisions of this amendment and the provisions of the Agreement, the provisions
of this amendment shall prevail.
7. Effective Date. This amendment shall be effective on December 10, 2021. While the
Agreement requires CMS to provide the Practice with 30 calendar days advance written
notice of any unilateral amendment, to the extent practicable, it was not practicable to
provide such notice for this amendment, which takes effect retroactively to the date of
enactment of the Protecting Medicare and American Farmers from Sequester Cuts Act.
[SIGNATURE PAGE FOLLOWS]

CENTERS FOR MEDICARE & MEDICAID SERVICES

Date: __________

By:

__________________________________________

Arrah Tabe-Bedward, Deputy Director, Center for Medicare and Medicaid Innovation