stack/docs/spec/2026-08-20-cy2027-iie-crossread-palliative-rfi.md

# CY2027 PFS NPRM § II.E Cross-Read — Pincites for the Palliative RFI Part (d)

Close read of section II.E ("Request for Information: Redesigning Primary
Care To Make America Healthy Again", 91 FR 43935–43946) of CMS-1848-P
(doc. 2026-14327), performed 2026-08-20 for issue #649. Source:
`data/fr_downloads/2026-14327.txt` lines 8278–9564. Paragraph counts: every
flush text block after a `[[Page NNNNN]]` marker counts as one ¶ (bullets and
"++" items included); headings, footnotes, and [GRAPHIC] lines don't count.
Jump links resolve via `stack bib fr-jump "91 FR <page> ¶<n>"`.

The condensed version of this analysis lives in
`notebooks/palliative_care_rfi.py` Section 6; this document carries the full
detail for P44 drafting (#650).

## The load-bearing finding

**Nothing in II.E is proposed.** The whole section is an RFI — every policy
idea is "seeking comment," "considering," or "may consider in future
rulemaking." The only operative care-management-adjacent text is the **G2211
changes proposed in section II.D**, cross-referenced at 91 FR 43937 ¶3 (with
proposed modifiers MOD1/MOD2 mentioned at 43937 ¶6). A part-(d) answer must
answer II.E's questions, not "support" nonexistent proposals — and can cite
CMS's own concessions as the agency-record predicate.

Drafting cautions:

- II.E never says "serious illness." Its vocabulary is *chronic conditions*,
  *complex condition*, *high-risk beneficiaries*, and (via NASEM) *people with
  multiple complex chronic conditions* (91 FR 43941 ¶9). Mirror it.
- The phrase "care management services that form the foundation" is the
  palliative RFI's own paraphrase — it does not appear in II.E; don't quote it
  as II.E text.
- Subsection numbering is inconsistent with the Introduction's promised
  "three main topics" (3. continues topic 2; 5. continues topic 4). Cite the
  printed numbers anyway.
- Tables A-E1 (care-management code purposes, 91 FR 43938) and A-E3
  (Innovation Center capitated models, 91 FR 43943) are graphics absent from
  the text file; pull from the PDF if needed.

## Subsection outline

| Subsection | FR pages | File lines |
|---|---|---|
| E. heading + 1. Introduction (start) | 43935 | 8278–8284 |
| 1. Introduction (three RFI topics) | 43936–43937 | 8287–8424 |
| 2. Reconsidering Relative Primary Care Payment / a. O/O E/M visits | 43937–43938 | 8425–8548 |
| 3. Care Management Code "Family" | 43938–43939 | 8549–8647 |
| 4. Payment Implications of Technology Enablement / a. Technology and Clinical AI | 43939–43940 | 8648–8767 |
| 5. Technology and AI-Augmentation via the Medicare AWV | 43940–43941 | 8768–8932 |
| 6. Developing Prospective Payment in the Shared Savings Program / a. Background | 43941–43943 | 8933–9207 |
| 6.b. Primary Care Capitated Payment Arrangements in SSP | 43943–43945 | 9209–9496 |
| 6.c. Capitated Arrangements Outside SSP (primary care "global period") | 43946 | 9500–9564 |

## CMS's concessions on the record

1. "uptake of the care management codes has been limited" + "We seek feedback
   on whether a different payment structure might be more appropriate as well
   as what might be done to further simplify the code set and associated
   requirements" — **91 FR 43938 ¶5**.
2. APCM "retains the fundamental structure of FFS billing and may not provide
   sufficient incentives for practices to focus on proactive,
   population-based non-visit care management activities" — **91 FR 43941
   ¶11** (CMS's critique of its own newest care-management code).
3. "billing for APCM services is higher for Shared Savings Program
   ACO-assigned beneficiaries... suggests that the accountability and care
   management infrastructure associated with ACOs may support more robust
   adoption of non-visit based primary care payment mechanisms" — **91 FR
   43942 ¶1** (internal CMS data).

## Care-management passages (verbatim anchors)

| Pincite | Quote / gist | Status |
|---|---|---|
| 91 FR 43936 ¶1 | "soliciting comment on how we might reconsider primary care service valuation"; prevention over "sick care" | DISCUSSED |
| 91 FR 43936 ¶3 | "considering first establishing PPCP permanently in the Medicare Shared Savings Program" | DISCUSSED |
| 91 FR 43936 ¶5 | "relative undervaluation"; "'two-track' approach to care management services... technology enabled... and 'traditional'" | RFI-QUESTION |
| 91 FR 43937 ¶2 | E/M visits "do not adequately describe the typical non-face-to-face care management work" (quoting 78 FR 43337) | DISCUSSED |
| 91 FR 43937 ¶3 | "We are proposing changes to HCPCS code G2211 for CY 2027; see section II.D" | **PROPOSED (in II.D)** |
| 91 FR 43937 ¶4 | longitudinal-visit category; "may consider valuing these visits as a combination of the E/M service... and certain between-visit care management activities" | DISCUSSED (future rulemaking) |
| 91 FR 43937 ¶6 | G2211 "focal point" question; proposed MOD1/MOD2 (elsewhere in rule) | RFI-QUESTION / PROPOSED-elsewhere |
| 91 FR 43938 ¶2 | "Should subsequent care management services be bundled in? If so, for what period of time?" | RFI-QUESTION |
| 91 FR 43938 ¶4 | "for the last 14 years sought to unbundle"; APCM G0556–G0558 "interprofessional care teams" | DISCUSSED |
| 91 FR 43938 ¶5 | limited uptake concession (above) | DISCUSSED + RFI-QUESTION |
| 91 FR 43938 ¶6 | "reconfigure the care management code 'family'... how supervision requirements may need to change" | RFI-QUESTION (part (d)'s direct hook) |
| 91 FR 43938 ¶8–43939 ¶1 | FWA guardrails: initiating-visit "trigger"; supervising-provider vs auxiliary-personnel proportions | RFI-QUESTION |
| 91 FR 43939 ¶2 | open data invitation: "specific data on the resources used in furnishing advanced primary care" | RFI-QUESTION |
| 91 FR 43939 ¶3 | "To what extent are the current care management codes duplicative?" | RFI-QUESTION |
| 91 FR 43939 ¶6 | "Should CMS create 'technology-enabled care management' codes or a 'two-track' approach?" | RFI-QUESTION |
| 91 FR 43939 ¶9 | "link payment more directly to demonstrated clinical outcomes" | DISCUSSED |
| 91 FR 43941 ¶9 | NASEM: "pay for primary care teams to care for people, not doctors to deliver services" | DISCUSSED (quoting NASEM 2021) |
| 91 FR 43941 ¶11 | APCM-not-the-end-goal concession (above) | DISCUSSED |
| 91 FR 43942 ¶1 | ACO care-management-infrastructure finding (above) | DISCUSSED |
| 91 FR 43944 ¶13 | minimum share of attributed beneficiaries receiving care management for capitation eligibility | RFI-QUESTION |
| 91 FR 43944 ¶16 | REACH/PC Flex PCC bundle: "E/M office visits along with CCM, behavioral health integration, transitional care management, AWVs, **advance care planning**, and virtual communication services" | DISCUSSED |
| 91 FR 43945 ¶14 | CPC+ care-delivery functions incl. "patient and caregiver engagement"; "increasing care management for high-risk beneficiaries" | RFI-QUESTION context |
| 91 FR 43945 ¶16 | "data-driven risk stratification methods to identify high-risk beneficiaries and target enhanced care management resources" | RFI-QUESTION |
| 91 FR 43946 ¶1 | attribution: plurality of primary-care services + voluntary alignment | DISCUSSED |
| 91 FR 43946 ¶2 | global period "would require a number of services to be 'bundled'... including the IPPE or AWV, O/O E/M services, and care management services such as advanced primary care management services" | DISCUSSED (future years) |
| 91 FR 43946 ¶3–¶8 | global-period design questions: what to bundle; HCC/complexity payment strata; initiating trigger absent an encounter; minimum-visit/outcomes accountability | RFI-QUESTION |

## Palliative hooks by RFI part

- **(b)/(c) eligibility**: longitudinal-visit construct (43937 ¶4); high-risk
  risk-stratification (43945 ¶16); HCC/complexity strata for global-period
  payment levels (43946 ¶4) — where serious-illness acuity tiers belong.
- **(d) service elements**: the 43938–43939 question cluster; APCM
  "interprofessional care teams" language (43938 ¶4); NASEM team framing
  (43941 ¶9); ACP inside the PCC bundle (43944 ¶16); AWV as a chassis for
  serious-illness screening and goals-of-care elicitation (43940 ¶9–43941 ¶6).
- **(e) quality**: outcomes-linked payment (43939 ¶9); FHIR-based outcome
  submission (43940 ¶3); "for which outcomes should CMS hold technology
  companies accountable?" (43941 ¶6) — openings for symptom burden, days at
  home, care-concordance, and CBE 3665.
- **(a) FWA**: initiating-visit trigger and supervision-proportion questions
  (43938 ¶8–43939 ¶1) map directly onto the palliative RFI's program-integrity
  part.
- **Data invitation** (43939 ¶2): a palliative program can submit its own
  staffing/cost data — the strongest "bring evidence" hook in the section.

## Drafting strategy for part (d)

1. Cite the II.D G2211/MOD1/MOD2 proposals as the rule's operative
   care-management-adjacent text (via 43937 ¶3/¶6).
2. Answer the 43938–43939 question cluster directly, pincite by pincite.
3. Use the three concessions (43938 ¶5, 43941 ¶11, 43942 ¶1) as the
   agency-record predicate for the PCM-1/2/3 code family (notebook Section 3):
   a care-management track for the population CMS's own data shows the current
   family fails to reach.