CMS Pub. 100-16, ch. 4, § 100.1

MA plans have significant flexibility in designing RI Programs that are specific to their

populations’ interests, abilities and needs. Plans are free to determine the specific

services, activities, or behaviors that are subject to rewards or incentives within their RI

Program design. Health-related services and activities associated with an RI Program

may include, for example, the utilization of a particular service(s) or preventive

screening benefit(s), adherence to prescribed treatment regimens, attending

education/self-care management lessons, meeting nutritional goals, and making and

keeping appointments with the doctor.

Plans may not discriminate based on health status, therefore, rewards and incentives

based on health outcomes may not be offered. However, enrollees may be rewarded for

continued healthy behaviors over time. For example, plans may not provide rewards and

incentives for the amount of weight lost or a lowered blood pressure, as those are health

outcomes and health status factors. Instead, the plan may provide rewards and/or

incentives to enrollees for reporting their weights or blood pressures at regular intervals.

Plans also may reward sustained behavior changes by enrollees in order to support and

promote the ultimate goal of RI Programs, which is lasting, positive changes in health-related behaviors. For example, an RI Program might include rewards and incentives for

those enrollees that report that they remain smoke-free at several time intervals after

completion of a smoking cessation program.

Note: Completion of a federally mandated survey, though arguably a health-related

activity, may not be included in an RI Program because of the potential for biased

responses due to the influence of rewards or incentives.