Umbrella Hub Arrangement Overview

Operate as one Medicare Diabetes Prevention Program (MDPP) supplier: In a UHA, the UHO is the MDPP enrolled supplier and subsidiary organizations do not separately enroll as MDPP suppliers. The subsidiary organizations participating in the UHA access Medicare reimbursement through the UHO’s MDPP supplier status.

Pursue sustainability and achieve economies of scale: Participation in a UHA can help the subsidiary organizations work together to pursue sustainability and achieve economies of scale. In the context of a UHA, sustainability refers to subsidiary organizations receiving long-term reliable reimbursement from public and private payers rather than short-term funding from sources such as federal grants. Benefits of scale and network adequacy occurs as more subsidiary organizations join the UHA. This collective impact makes the network more attractive to health care payers.

Streamline billing, claims, and administrative support: Many CDC-recognized organizations face challenges in successfully billing Medicare and other health care payers to receive reimbursement. A key element of a UHA is a single billing and claims submission platform used by all subsidiary organizations. For example, the billing and claims platform can either be an existing in-house platform used by the UHO that all subsidiary organizations can access, or it can be a contracted third-party platform.

Share CDC-recognition status: To join a UHA, each subsidiary organization must have pending, preliminary, or full recognition; however, while participating in the arrangement, all subsidiary organizations assume the recognition status of the UHO. This shared recognition status has several benefits, including enabling subsidiary organizations that entered the UHA with pending recognition to access Medicare reimbursement through the UHO’s collective recognition status. Additionally, once a UHA achieves full plus recognition, it will be allowed to maintain that status indefinitely as long as it continues to submit data.

Promote health equity: UHAs support partners in activating and advancing goals related to health equity. The UHA provides a mechanism for the UHO, subsidiary organizations, convening partners, referral sources, and community-based entities to screen and address unmet health-related social needs (HRSN) that contribute to health disparities. Conversations about how UHAs can support health equity may begin with a clear understanding of the terms related to health equity. Definitions related to health equity are outlined in the following table. Additional information and resources are available on the Defining Health Equity page of the Coverage Toolkit.

• Health Equity: the state in which everyone has a fair and just opportunity to attain their highest level of health.
• Health Disparities: a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage.
• Social Determinants of Health (SDOH): the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality of life outcomes and risks.
• Health-Related Social Needs (HRSN): immediate individual or family needs impacted by social and economic conditions (i.e., housing insecurity, food insecurity, or lack of reliable transportation).

Changes in insurance coverage during a one-year program can impact participant retention and CDC-recognized organization reimbursement for delivering the National DPP lifestyle change program. This can be especially challenging for providers serving Medicaid beneficiaries, who may move between Medicaid MCOs or on and off Medicaid as numerous factors impact their eligibility. UHAs may offer an opportunity for participants to continue the lifestyle change program without interruption, as these entities often hold contracts with a variety of payers including Medicaid, MCOs, and commercial health plans. For more information on churn within Medicaid, see the Reimbursement page of the Coverage Toolkit.

Align the Core Mission and Vision of the UHA

The UHA aims to increase the capacity of organizations to deliver the National DPP lifestyle change program. Core mission alignment between the UHO and subsidiaries is essential to the foundation of the UHA and should be addressed prior to development of the UHA. Mission alignment can streamline development of the UHA, build trust between UHA partners, and strengthen the organizational capacity to provide a unified direction for all involved. For example, communicating a broader vision for the UHA—such as lowering the incidence of type 2 diabetes in a specific community—can help strengthen organizational commitment to operationalize the UHA.

• Focus on the UHA’s mission: Keeping overall goals in mind (e.g., supporting subsidiary organizations in their efforts to deliver the National DPP lifestyle change program to prevent type 2 diabetes) helped the Demonstration UHOs navigate the challenges of starting a new business arrangement. Documenting goals and mission statements helped the organizations define shared objectives. To learn how Demonstration UHOs used charters to define the UHA’s mission, see the charters section of the Business Model for Umbrella Hub Arrangements page and refer to sample charters (charter example 1 and charter example 2) developed by UHOs.

Develop a Workplan to Operationalize the UHA

Potential UHOs are encouraged to inventory their internal resources such as staffing, administrative capacity, and financial status, and compare those resources to the resources necessary to operationalize a UHA. Additionally, UHO staff should have a detailed understanding of the National DPP lifestyle change program. This will facilitate the UHO’s ability to operationalize the UHA and provide support for subsidiary organizations. The UHA Project Planning Template can be used to assist organizations with the planning phases of a UHA. The template can serve as a guide for organizing thoughts and tracking efforts related to UHA planning and can be adapted to fit unique organizational needs or goals. While the UHA Project Planning Template was originally developed to assist UHAs interested in enrolling in Medicaid and/or contracting with managed care organizations, content can be adjusted to fit organizations interested in prioritizing Medicare Diabetes Prevention Program (MDPP) enrollment and/or commercial payer partnerships.

Additionally, the UHA Modifiable Slide Deck can be utilized to guide organizations through efforts to implement sustainable UHA partnerships and processes. It is recommended that organizations serving as the UHO or participating in a convener role modify the deck as needed and use it in initial conversations with partners to educate them and/or to help make the case for participation in a UHA. You can learn more about the UHA Modifiable Slide Deck and how to use it, by reading through the accompanying UHA Modifiable Slide Deck – Introduction.

• Understand the time commitments required to operationalize the UHA: Demonstration UHOs found the start-up phase took between 6-12 months. This included gathering the necessary documents and requirements for the MDPP application, meeting with subsidiary organizations to explain the details of the UHA, determining and explaining how the UHO would distribute claims payments to subsidiary organizations, and meeting with senior leadership to discuss decisions about the UHA. Information on start-up costs associated with these activities are available on the Business Model for Umbrella Hub Arrangements page.
• Develop a work plan: Demonstration UHOs found that a work plan helped identify the key tasks, timeline, staff, and resources needed to operationalize the UHA. A detailed work plan can help UHOs stay on track with actions such as recruiting subsidiary organizations, completing CDC’s UHA application, executing contracts with subsidiary organizations, enrolling in Medicare, adding subsidiary organizations to a Medicare enrollment, and establishing accounting processes for claims reimbursement distribution. The UHA Project Planning Template can be used to create a work plan.

Develop or Contract with a Billing and Claims Platform

A function of a UHA is to submit claims to public (Medicare and Medicaid) and commercial health care payers on behalf of the subsidiary organizations. It is recommended that organizations seeking to serve as a UHO assess their willingness and capacity to work with a billing and claims vendor or determine whether they have an in-house platform to submit claims that all subsidiary organizations could easily access and use. The billing and claims vendor may be able to create multiple efficiencies for subsidiary organizations including streamlining the referral and enrollment process, simplifying participant data entry, recording attendance and weight loss milestones, and submitting data to CDC and claims to health care payers.

When selecting a billing vendor, UHOs are encouraged to consider their budget, personnel, resources, and the cost of the billing platform relative to the payer reimbursement rate and any administrative fees the UHO may charge subsidiary organizations. CDC’s UHA guidance document, found on the National DPP UHA Guidance and Application page on their National DPP Customer Service Center, states that start-up costs and/or ongoing operational costs associated with the use of billing platform or vendor are handled between the UHO and the subsidiary organizations and CDC will not review these business arrangements. However, CDC has developed guidance for CDC-funded recipients on purchasing billing and delivery platforms, available here.

• Build a strong and lasting relationship with a billing vendor: The UHOs that participated in the Demonstration contracted with a vendor to submit claims. Demonstration UHOs and their billing vendor, Welld Health, fostered a strong working relationship. Welld Health has provided technical assistance to the Demonstration UHOs as they operationalize and continues to provide ongoing trainings, maintenance, and payer updates for the Demonstration UHOs.
• Schedule training sessions with subsidiary organizations: Demonstration UHOs scheduled training sessions for subsidiary organizations to help them feel comfortable using the platform to submit claims and to understand the extent of its capabilities.
• Define and communicate the roles, responsibilities, and timelines for the UHO, the subsidiary organizations, and the billing platform: UHOs should educate subsidiary organizations on the roles and required timelines for data entry in the billing platform. Claims denied because of inaccuracies can be costly and time consuming, so it is incumbent on the UHO and subsidiary organizations to work together to ensure submitted claims are accurate and on time.

Evaluate the Business Acumen Required to Operate a UHA

The UHA relies on the UHO to handle reimbursements and make business related decisions for the UHA. It is recommended that potential UHOs assess their readiness to engage in all business and financial requirements associated with UHA participation. For additional resources to evaluate an organization’s capacity to serve as a UHO, please reference the UHO Capacity Assessment and Tips for Identifying Potential UHOs tools.

• Determine if the UHO has sufficient infrastructure to handle reimbursements: UHOs are tasked with receiving reimbursement payments from CMS and other health care payers and distributing them to subsidiary organizations. Consider whether the UHO has the experience or adequate resources to handle reimbursement payments. For example, one Demonstration UHO had concerns with directly receiving claims reimbursements and then redistributing the reimbursements to their subsidiary organizations who provided the services. It took several conversations to resolve these concerns and to formulate a plan on how to accomplish these tasks.
• Develop a business model: Demonstration UHOs developed business models to support the UHO and the subsidiary organizations. The Business Models encompass four major areas of business categories, each deserving attention. These include how to appeal to customers, how to identify revenue sources, and how to understand costs. To learn more about UHA business models, see the Business Model for Umbrella Hub Arrangements page.
• Inventory data management capabilities: Demonstration UHOs developed data management and storage protocols and implemented security measures to meet Health Insurance Portability and Accountability Act (HIPAA) standards.

Create a Financial Sustainability Plan

The UHO is responsible for the long-term financial sustainability of the UHA. Per CDC’s UHA guidance, found on the National DPP UHA Guidance and Application page of the National DPP Customer Service Center, UHOs are required to activate an agreement with at least one payer within two years of submitting their UHA application. Because of this, UHOs are encouraged to enroll as a MDPP supplier and in state Medicaid programs (where applicable), and to contract with Medicaid managed care organizations (MCOs), Medicare Advantage (MA) plans, commercial health plans, and self-insured employers. For more information about financial sustainability and potential health care payers, see the Reimbursement for Umbrella Hub Arrangements page. Other factors that contribute to the overall sustainability of the UHA can be found in Sustaining Umbrella Hub Arrangements page.

• Evaluate the organization’s ability to operate as an MDPP supplier: The Demonstration UHOs were not MDPP suppliers prior to becoming UHOs. The process to become a MDPP supplier can take several months and involves dedicated staff time and persistence. Demonstration UHOs experienced some unexpected delays, particularly with their MDPP enrollment application, which contributed to extended timelines and added costs. For more information about becoming a MDPP supplier, see the UHO MDPP Supplier Enrollment Guide.
  
• Consider additional revenue sources: At least two Demonstration UHOs aspire to have Medicaid MCOs or other commercial health care payers help fund the UHA to minimize what subsidiary organizations must pay to participate in the UHA. These talks with commercial health care payers remain ongoing as of March 2022. To learn more about UHA revenue sources, see the Reimbursement for Umbrella Hub Arrangements page.

Establish UHA Communication and Coordination Protocols

UHAs involve internal coordination with subsidiary organizations and external coordination with partners, including health care payers, referral partners, state partners, and possibly a billing and claims vendor. Potential UHOs are encouraged to assess their capacity for ongoing communication and coordination with UHA partners. Resources, such as the UHA Modifiable Slide Deck, which has been designed to support such relationship building efforts, can be used to assist UHOs in developing marketing and communication strategies for their UHA. Specifically, it is recommended that organizations serving as the UHO or participating in a convener role modify the deck as needed and use it in initial conversations with partners to educate them and/or to help make the case for participation in a UHA. You can learn more about the UHA Modifiable Slide Deck and how to use it, by reading through the accompanying UHA Modifiable Slide Deck – Introduction.

• Educate partners: As early adopters, Demonstration UHOs educated key partners—such as commercial health care payers, state Medicaid agencies, and their state health departments—on the basic components and purpose of a UHA. As UHAs become more prevalent the need for education should decrease; however, new UHOs are wise to expect the need for some level of education for the key partners in their arrangement.
• Engage in ongoing communication with subsidiary organizations: Demonstration UHOs held regular meetings with the subsidiary organizations and the billing and claims vendor to maintain or establish strong relationships with all UHA participants. Open communication and transparent decision making helped UHA participants understand the goals of the arrangement.

Identify and Recruit Subsidiaries

The UHA can benefit from economies of scale as the number of subsidiary organizations increases. The following are considerations when onboarding new subsidiary organizations into the UHA.

• Willingness to partner in an innovative program: Potential subsidiary organizations will need to be familiar with the commitments and requirements of participating in a UHA. These may include a willingness to educate partners on the Business Model for Umbrella Hub Arrangements, a willingness to enter into contractual agreements, including business associate agreements (BAAs) and data use agreements, and a willingness to contribute to the UHA’s financial strategy.
• Need for billing and administrative assistance: Assessing the administrative capacity and needs of subsidiary organizations are important factors for subsidiary retention and UHA sustainability. UHOs should develop an understanding of the subsidiary organization’s current billing and administrative needs and the resource commitment that will be required from the UHO to meet these needs.
• Ability to reach priority populations: One goal of the UHA can be to advance equity and access to the National DPP lifestyle change program. UHOs may consider recruiting subsidiary organizations that serve priority populations, have beneficial relationships with health care providers, or that serve a new geographic area.

The Subsidiary Onboarding and Engagement Checklist was developed to help UHOs engage with potential subsidiary organizations, obtain commitment from subsidiary organizations to participate in the UHA, and orient subsidiary organizations to their roles and responsibilities. This checklist outlines the potential workflow between the UHO and subsidiary organizations and is intended to serve as a guide for the onboarding and engagement processes with subsidiary organizations. While the Subsidiary Onboarding and Engagement Checklist provides guidelines and time estimates for the onboarding process, it may not reflect all timelines or steps needed for every UHA. UHOs are encouraged to make adjustments to fit their unique needs.

To assess an organization’s familiarity and interest in joining the UHA as a subsidiary, review the UHA Questionnaire for CDC-Recognized Organizations.

• Understand the value proposition of the UHA and needs of individual subsidiary organizations: While identifying and recruiting subsidiaries, Demonstration UHOs developed the value propositions described above and adapted recruitment strategies to align with individual organizational needs.
• Use the UHO’s network as a starting point: Demonstration UHOs had strong relationships with each of their original subsidiary organizations. These strong relationships allowed for trust between the UHOs and their subsidiary organizations, which was valuable given the novelty of the UHA concept and the unknowns inherent in participating in the Demonstration.
• Maintain consistent outreach and recruitment efforts: The sustainability of the UHA is increased as additional subsidiary organizations join the arrangement. Demonstration UHOs regularly discuss the benefits of UHA participation with potential subsidiary organizations. Demonstration sites also report engaging potential subsidiary organizations during other projects or meetings to maintain communication and build relationships.
• Recognize the reasons a potential subsidiary organization may not want to join the UHA: In addition to understanding and communicating the value proposition of the UHA, knowing the reasons a potential subsidiary organization chooses not to join the UHA can help the UHO target future outreach. For example, Demonstration UHOs found that some potential subsidiary organizations were concerned about the costs of participating in the UHA or already had billing and claims submission capabilities.
• Identify additional ways UHOs can help increase subsidiary organizational capacity: Demonstration UHOs are currently exploring and implementing ways to provide additional support to their subsidiary organizations. This includes training and retention of Lifestyle Coaches and reviewing expectations of Lifestyle Coaches to provide services in a UHA (e.g., obtain an NPI).