Health at Home Challenge

Phase 1: Implementation Strategy (April 2026-July 2026)

The goal of Phase 1 is to reward implementation strategies to scale comprehensive services that reach large numbers of higher-need dually eligible and near-dually eligible Medicare and Medicaid beneficiaries through partnerships between advanced community care networks and health care organizations. 

Key components of this strategy should include:

• Estimated number of dually eligible and near-dually eligible Medicare and Medicaid beneficiaries currently served and estimated to be served through the advanced community care network and health care team
• Ability to deliver a set of core services:
  • Community-based navigation
  • Community-based care coordination and care management
  • Community-based care transitions
  • Evidence-based health promotion programs
  • Nutrition services
• Geographic reach of network partners that support volume and type of services delivered (e.g., statewide or multi-state)
• Technology assets and a shared leadership/governance structure that supports community-clinical integration and the ability to scale to reach a broader geography or larger volume of individuals
• Timeline for full implementation of strategy

Prizes for Phase 1

A total of up to $2 million in prizes will be awarded to a maximum of 10 teams that best meet the judging criteria.

Watch the informational webinar | webinar slides
 

Phase 2: Implementation Accelerator (August 2026-July 2027)

The goal of Phase 2 is to reward Challenge teams for accelerating implementation of the strategies they proposed in Phase 1 to deliver comprehensive, person-centered services to improve independence and health at home for large numbers of higher-need dually eligible and near-dually eligible Medicare and Medicaid beneficiaries. The Challenge teams, comprised of advanced community care networks and healthcare organizations, will work together to integrate health and community care, increase the days home, and reduce the total cost of care.

Key components of the end of Phase 2 submission outline should include:

• At-a-glance assessment of the degree to which Phase 2 work matches Challenge goals
• Sufficient — and improved — capability in the list of competencies of an advanced community care network, including metrics to quantify sufficient and improved progress, when possible
• Demonstration of how your advanced community care network delivered the person-centered core services to the target population, including metrics to quantify sufficient and improved progress, when possible:
  • Community-based navigation
  • Community-based care coordination and care management
  • Community-based care transitions
  • Evidence-based health promotion programs
  • Nutrition services
  • Optional: additional whole-person health programs and services, such as those focused on housing stability, transportation, dementia care supports, caregiver supports, physical activity, and more
• Assessment of accelerated reach of core services, including metrics to quantify sufficient and improved reach relative to an established baseline, across three dimensions of reach:
  • A significant volume and proportion of the target population
  • An expanded geography beyond your baseline operating geography
  • An expanded network, including number of healthcare partners and number of service delivery partners

Prizes for Phase 2

A total of up to $2 million in prizes will be awarded to a maximum of five Phase 2 winning teams that best meet the judging criteria.

Up to three teams, regardless of whether or not they are a Phase 2 prize winner, could be eligible for an additional meritorious prize of up to $50,000 for one of the following focus areas:

• Implementation of artificial intelligence (AI) to enable community-clinical integration and coordinated service delivery for dually eligible and near-dually eligible beneficiaries
• Innovative approaches to reach the near-dually eligible beneficiaries with complex needs and at risk for spend down to Medicaid eligibility
• Innovative and expansive “shared services” approach to share infrastructure (e.g., technology, administrative, contractual, financial) with one or more additional network-based partners — other CCHs, area agencies on aging (AAAs), centers for independent living (CILs) that each have their own CBO network — to substantially improve reach
• Outstanding collaboration and sharing of strategies and learnings with other Challenge teams

Phase 3: Scaling for Impact (August 2027-July 2028)

The goal of Phase 3 is to demonstrate the scaling and impact of the winning teams’ interventions selected in Phase 2. 

Prizes for Phase 3

A total of up to $2 million in prizes will be awarded to a maximum of three teams that best meet the judging criteria.

Up to three prize winners could be eligible for additional meritorious prizes of up to $50,000 for:

• Implementation of AI to enable community-clinical integration and coordinated service delivery for dually eligible and near-dually eligible beneficiaries
• Innovative approaches to reach the near-dually eligible beneficiaries with complex needs and at risk for spend down to Medicaid eligibility

End of Phase 2 Submissions

Phase 2 participants must submit this information to be considered for a Phase 2 prize and continuation into Phase 3.

Submissions are due by Wednesday, June 23, 2027, at 5:00 p.m. ET. The designated primary point of contact must submit the completed materials by emailing them to healthathome@acl.hhs.gov no later than the stated deadline.

A diverse panel of experts with competencies in aging and disability services, CCHs, Medicare and Medicaid, and healthcare financing and contracting will evaluate all submissions in each phase of the Challenge. The evaluation team will include both governmental and non-governmental representatives.

Judges will evaluate the extent to which submissions meet the following requirements. These requirements will be based on detailed information each Phase 2 Challenge team is expected to produce at the end of Phase 2.

Submission Requirements

Submissions for the end of Phase 2 of the Challenge shall meet the following requirements. All submissions must:

• Address the information described in the submission outline.
• Be written in English and use clear, straightforward, and concise language.
• Be submitted in PDF or Microsoft Word format.
• Not exceed 15 pages in length, excluding cover page and appendices, which are limited to a total of 10 pages.
• Use 1-inch margins.
• Use a widely available font face (e.g., Arial, Helvetica, Times New Roman, Georgia).
• Use at least 11-point font, except for charts and tables, which must be at least 9-point font.
• Not use U.S. Department of Health and Human Services (HHS), ACL, or other government logos or official seals in their submission or otherwise imply federal government endorsement.

Submission Outline

Cover Page and Contact Information

• Full name of organization acting as the team lead
• Mailing address including city, state, zip code
• Primary contact name
• Primary contact telephone number (including area code)
• Primary contact email address
• Project title

Section 1: At-a-Glance Assessment of Progress toward Challenge Goals (10 points)

The purpose of this section is to provide an at-a-glance assessment of the degree to which Phase 2 work matches Challenge goals.

Provide detailed information on how your Phase 2 work indicates successful progress toward the Challenge goals. If your Phase 2 work involves a divergent implementation strategy than originally proposed in Phase 1, clearly explain the reason for a pivot and how the new strategy facilitated improved and successful progress toward the Challenge goals.

• Describe how your implemented strategy meets the definition of an advanced community care network: that it represents collaboration across one or more CCHs integrated with at least one healthcare partner to deliver comprehensive, person-centered services to improve the affordability of high-quality care and independence at home for a large population of dually eligible and near-dually eligible Medicare and Medicaid beneficiaries with multiple chronic conditions and at least one functional limitation.
  • Describe how you grew the size or scope of the advanced community care network.
  • Describe how the network of aging and disability CBOs were able to be responsive to and meet the needs of duals and near-duals as the network service area grew, while maintaining a person-centered approach.
• Describe how you addressed barriers to sustainable community-clinical partnerships, including lack of infrastructure, workflow integration, referral volume, and braiding of available funding sources for services.
• Describe how you used a continuous quality improvement mindset to assess and improve outcomes or operational performance over time, including through strategic pivots, when appropriate.
• Describe how you engaged in peer-based learning with other Phase 2 Challenge teams to advance the field and the goals of the Challenge (e.g., sharing lessons and strategies, mentoring peers, informing shared services implementations across advanced community care networks, etc.).
   

Section 2: Acceleration of the Advanced Community Care Network (25 points)

Provide detailed information about how you demonstrated sufficient — and improved — capability in the following list of competencies of an advanced community care network. Include metrics to quantify sufficient and improved progress across Phase 2, when possible.

• Contract with health plans, health systems, or accountable care organizations.
• Serve a large geographic area with reach that can be regional, statewide, or multistate.
• Maintain the capacity to serve large volumes of people across the network while maintaining a person-centered approach.
• Provide a diverse set of person-centered community-based services to advance health and well-being.
• Achieve a mature degree of community-clinical partnership and integration (e.g., workflow integration, seamless care coordination and delivery across sites, etc.).
• Maintain a robust infrastructure that supports scaling resources and services while reducing operational costs (e.g., via the four domains of functions and infrastructure for advanced community care networks: strategy and governance; business and technology infrastructure; data, performance, and impact; and network management).
• Demonstrate high performance through strong technology and data systems that enable measurement of impact, continuous quality improvement, and outcomes reporting.

Relative to an established baseline, examples could include but are not limited to: increasing monthly/quarterly growth rates, onboarding of new staff or providers, new network partners (healthcare, AAAs, CBOs, other CCHs, etc.), usage of new or shared infrastructure and functions for the network (such as information technology, contract support services, revenue cycle management, regulatory compliance and data security, network performance management, training and technical assistance), etc.
 

Section 3: Acceleration of Core Service Delivery (25 points)

Provide detailed information about how your advanced community care network delivered the following person-centered core services to the target population. Include metrics to quantify sufficient and improved progress across Phase 2, when possible.

• Community-based navigation
• Community-based care coordination and care management
• Community-based care transitions
• Evidence-based health promotion programs
• Nutrition services
• Optional: additional whole-person health programs and services, such as those focused on housing stability, transportation, dementia care supports, caregiver supports, physical activity, and more

Relative to an established baseline, examples could include but are not limited to: increasing monthly/quarterly service provision rates, client engagement rates, person-centered plans in place, referral rates, referral conversion rates, wait time for services, availability of services (such as hours, days, locations, modalities), client satisfaction with services, lower per-person service costs, clients served and service encounters per provider, any preliminary process or outcome measures showing interim success of the core services, etc.

Describe how you demonstrated the ability to maintain and increase the availability and number of qualified staff or network partners to deliver person-centered core services. Include metrics to quantify sufficient and improved progress across Phase 2, when possible. Relative to an established baseline, examples could include but are not limited to: increasing monthly/quarterly provider workforce numbers, workforce satisfaction, workforce recruitment and retention, client satisfaction with workforce, workforce training and technical assistance, workforce labor costs and efficiency, usage of new and/or shared infrastructure for the workforce, etc.

When relevant and possible, describe coordination with other aging and healthcare programs, funding, organizations, and infrastructure in the service areas but not formally part of the Challenge team’s advanced community care network, such as:

• ACL’s evidence-based programs for disease prevention and health promotion, falls prevention, Senior Nutrition Program, and other relevant programs provided by AAAs, aging and disability resource centers (ADRCs), and CILs
• CMS’ healthcare models that can facilitate Challenge goals, like AHEAD, ELEVATE, GUIDE, LEAD, MSSP
• Other healthcare infrastructure or major providers, such as Medicare Advantage plans, Dual Eligible Special Needs Plans, Health Information Exchanges, other local health systems, Medicaid managed care organizations or plans, etc.
   

Section 4: Assessment of Accelerated Reach (by both geography and volume served) (40 points)

Provide detailed information about how your advanced community care network provided core services to the target population across the following dimensions of reach. Include metrics to quantify sufficient and improved reach across Phase 2 relative to an established baseline, when possible. Examples could include, but are not limited to, those listed in the parenthetical phrases within each bullet below:

• A significant volume and proportion of dually eligible, near-dually eligible, or other populations with multiple chronic conditions and at least one functional limitation in your geography (e.g., absolute and relative percentages of people served, service encounters, subpopulations reached, etc.)
• An expanded geography beyond your baseline operating geography (e.g., new neighborhoods, zip codes, counties, or crossing state lines; new rural, urban, or otherwise underserved communities reached, etc.)
• An expanded network including number of healthcare partners (e.g., Medicare Advantage plans, Special Needs Plans, or other health plans; Medicare accountable care organizations (ACOs) or other ACOs; health systems; provider groups or other Medicare fee-for-service billing entities) and number of service delivery partners (e.g., CBOs, AAAs, ADRCs, CILs, other aging and disability network providers, etc.)

When relevant, describe how the usage of new or shared infrastructure and functions enabled and accelerated your ability to reach greater volumes, geographies, and network partners (e.g., technology, administrative, contractual, financial), especially if those shared services enabled access to new network-based partners (e.g., other CCHs, AAAs, CILs that each have their own CBO network).
 

Consideration for meritorious prizes

This section is not used for scoring but will be used to identify potential Phase 2 meritorious prize winners. Consider these as you write your end of Phase 2 submission.

• Did the Challenge team utilize AI to enable person-centered community-clinical integration and coordinated service delivery for dually eligible and near-dually eligible beneficiaries? Did this reduce burden, improve care coordination, or improve the efficiency of care?
• Did the Challenge team utilize innovative person-centered approaches to reach near-dually eligible beneficiaries with complex needs and at risk for spend down to Medicaid eligibility? Were the approaches innovative and impactful?
• Did the Challenge team utilize an innovative and expansive “shared services” approach to share infrastructure (e.g., technology, administrative, contractual, financial) with one or more additional network-based partners (i.e., other CCHs, AAAs, CILs that each have their own CBO network) to substantially improve reach?
• Did the Challenge team go above and beyond in collaborating and sharing strategies and learnings with other Challenge teams? 
   

Judging Criteria (Phase 1 – Implementation Strategy)

A diverse panel of experts with competencies in aging and disability services, CCHs, Medicare and Medicaid, and health care financing and contracting will evaluate all submissions in each phase of the Challenge. The evaluation team will include both governmental and non-governmental representatives.

Judges will evaluate the extent to which submissions meet the following requirements.

Section 1: Demonstration of Need and Responsiveness (10 points)

Does the implementation strategy clearly meet the goals of the Challenge? Namely, does it:

• Demonstrate how committed teams of advanced community care networks and health care partners can integrate the delivery of comprehensive, person-centered services to improve the affordability of high-quality care and independence at home for a large population of dually eligible and near-dually eligible Medicare and Medicaid beneficiaries?
• Address the barriers to sustainable community-clinical partnerships, including lack of infrastructure, workflow integration, referral volume, and braiding of available funding sources for services?
• Demonstrate how trusted networks of aging and disability CBOs, supported through community care hubs, can be responsive to and scale to meet the needs of duals and near-duals, consistent with the service area of their health care partners?

Section 2: Commitment of Health Care Partner(s) (20 points)

Does the implementation strategy represent collaboration across one or more CCHs and at least one health care partner, including a letter of commitment from the health care partner(s)? Does the submission articulate the role and commitment of the health care partner to achieve the goals of the Challenge, including any contractual arrangements to support the delivery and financing of core services?

Section 3: Competency as an Advanced Community Care Network (20 points)

Does the lead applicant possess the requisite competencies of an advanced community care network, represented by its ability to:

• Contract with health plans, health systems, or accountable care organizations?
• Serve a large geographic area with reach that can be regional, statewide, or multistate?
• Maintain the capacity to serve large volumes of people across its networks? 
• Provide a diverse set of community-based services to advance health and well-being?
• Maintain a robust infrastructure that supports scaling resources and services while reducing operational costs?  
• Demonstrate high performance through strong technology and data systems that enable impact measurement and outcomes reporting?

Section 4: Capacity to Deliver Core Services at Scale (20 points)

Is there demonstrated capacity to deliver core services at scale across the advanced community care network, including:

• Documentation of existing service delivery to the target population of individuals dually eligible for Medicare and Medicaid, as well as those near-dually eligible?
• Availability of trained and qualified staff to deliver core services?
• Established network partners with the capacity to deliver services at scale?

Section 5: Geographic Areas of Interest (15 points)

Does the advanced community care network-health care partnership represent one or more of the identified areas of interest or does it demonstrate a high level of readiness and opportunity to address Challenge goals consistent with the factors used to identify these areas? These factors include:

• Presence of advanced community care networks that are partnering with health care organizations
• Market penetration of Medicare Advantage, Special Needs Plans, and Medicare Accountable Care Organizations
• Alignment with CMS Star rating gaps and opportunities for quality improvement

Section 6: Estimated Volume of Individuals Dually Eligible for Medicare and Medicaid and Near-Duals (15 points)

Does the implementation strategy reflect an estimated reach to a significant proportion of dually eligible and near-dually eligible beneficiaries in their state (i.e., up to 100,000 individuals served)? Does the submission include the applicant’s current reach of core services to the target population and their estimated expansion during the Challenge timeframe (Phase 2 and Phase 3)?

Eligibility

To be eligible to win a prize, the Challenge team:

• Shall have complied with all the requirements under this section.
• Must represent a partnership between an advanced community care network and at least one health care organization. Multiple CCHs can collaborate on a submission, but one CCH must be designated as the Challenge team lead. This CCH must be connected to an area agency on aging, an aging and disability resource center, a center for independent living, or another aging or disability network organization. 
• Must include with their submission a commitment letter from at least one health care partner, as well as any key community partners as relevant.  
• Must agree to participate in an external evaluation to measure the impact of services delivered to dually eligible and near-dually eligible beneficiaries as a condition to progress to subsequent phases if awarded in Phase 1.
• Shall, in the case of a private entity, be incorporated in and maintain a primary place of business in the U.S. In the case of a team, the team leader shall be a U.S. citizen or permanent resident. However, non-U.S. citizens and non-permanent residents can participate as members of a team or entity that otherwise satisfies the eligibility criteria. Non-U.S. citizens and non-permanent residents are not eligible to win a monetary prize (in whole or in part). Their participation as part of a winning team or entity, if applicable, may be recognized at the announcement of the results. In the case of an individual, whether participating singly or in a group, they shall be a citizen or permanent resident of the U.S.
• Shall not be a federal entity or federal employee acting within the scope of their employment (all non-HHS federal employees must consult with their agency ethics official to determine whether the federal ethics rules will limit or prohibit the acceptance of a COMPETES Act prize).
• Shall not be an employee of (HHS) or any other component of HHS acting in their personal capacity.
• Shall not be a judge of the Challenge, or any other party involved with the design, production, execution, or distribution of the Challenge or the immediate family of such a party (i.e., spouse, parent, stepparent, child, or stepchild).
• May, in the case of federal grantees, not use federal funds to develop submissions unless consistent with the purpose of their grant award.
• May, in the case of federal contractors, not use federal funds from a contract to develop COMPETES Act challenge submissions or fund efforts in support of a COMPETES Act challenge submission.
• Shall be 18 years of age or older at the time of submission.

Participation Requirements

• An individual, entity, or team shall not be deemed ineligible because the individual or entity used federal facilities or consulted with federal employees during a competition if the facilities and employees are made available to all individuals and entities participating in the competition on an equitable basis.
• Federal grantees and recipients of cooperative agreements may not use federal funds to develop their Challenge submissions unless use of such funds is consistent with the purpose of their grant award and specifically requested to do so due to the Challenge design. If a participant uses federal grant or cooperative agreement funds to win the Challenge, the prize must be treated as program income for purposes of the original grant or cooperative agreement in accordance with applicable Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards [2 CFR § 200].
• Multiple entries are permitted. Each solution must be sufficiently novel and unique and not be a minor modification of a prior submission.
• By participating in this Challenge, each participant (whether a team or entity) agrees to assume any and all risks and waive claims against the federal government and its related entities, except in the case of willful misconduct, for any injury, death, damage, or loss of property, revenue, or profits, whether direct, indirect, or consequential, arising from participation in this prize contest, whether the injury, death, damage, or loss arises through negligence or otherwise.
• Participants are required to obtain liability insurance or demonstrate financial responsibility for claims by a third party for death, bodily injury, or property damage, or loss resulting from an activity carried out in connection with participation in this Challenge.
• Participants must also agree to indemnify the federal government against third-party claims for damages arising from or related to Challenge activities.
• By participating in this Challenge, each participant (whether a team or entity) warrants that they are sole author or owner of, or has the right to use, any copyrightable works that the submission comprises, that the works are wholly original with the participant (or is an improved version of an existing work that the participant has sufficient rights to use and improve), and that the submission does not infringe any copyright or any other rights of any third party of which the participant is aware.
• As a condition for winning a cash prize in this Challenge, each participant (whether participating as a team or entity) grants to ACL an irrevocable, paid-up, royalty-free nonexclusive worldwide license to reproduce, publish, post, link to, share, and display publicly the team/entity name, title, executive summary, and plain language summary components of the submission on the web or elsewhere. Each participant will retain all other intellectual property rights in their submissions, as applicable. To participate in the Challenge, each participant must warrant that there are no legal obstacles to providing the above-referenced nonexclusive licenses of the participant’s rights to the federal government.
• Each participant (whether a team or entity) agrees to follow all applicable federal, state, and local laws, regulations, and policies.
• Contestants to this Challenge must agree to be bound by the rules of the Challenge, agree that the decision of the judges for this Challenge are final and binding, and acknowledge that their submission may be the subject of a Freedom of Information Act (FOIA) request and that they are responsible for identifying and marking all business confidential and proprietary information in their submission.
• As a condition for winning a cash prize in this Challenge, each participant (whether participating as a team or an entity) irrevocably grants to ACL the right to the use of their name, affiliation, city and state, and likeness or image for publicity releases and any other promotion of this Challenge.
• Submitting teams are only eligible to compete for Phases 2 and 3 of the Challenge if they are selected as a winner in the previous phase. Only Phase 1 winners are eligible for Phase 2; only Phase 2 winners are eligible for Phase 3. ACL reserves the right to cancel, suspend, and modify the Challenge, or any part of it, for any reason, at ACL’s sole discretion.

Awarding the Prize 

Prizes awarded under this Challenge will be paid via electronic funds transfer and may be subject to federal income taxes. HHS and ACL will comply with the Internal Revenue Service (IRS) withholding and reporting requirements, where applicable.

Entities participating in this Challenge are encouraged, but not required, to request and obtain a free Unique Entity ID (UEI), if they have not already done so, via SAM.gov,as this will expedite prize payment.

For team submissions, if a cash prize is awarded, the prize will be paid in full to the designated team leader, who is solely responsible for distributing the prize funds among team members.  

For entity submissions, if a cash prize is awarded, the prize will be paid directly to the entity and not the entity’s point of contact. HHS and ACL will not arbitrate, intervene, advise on, or resolve any disputes or arrangements among team members. 

Statutory Authority to Conduct the Challenge 

ACL is conducting this Challenge under the America Creating Opportunities to Meaningfully Promote Excellence in Technology, Education, and Science (COMPETES) Reauthorization Act of 2010, as amended, 15 U.S.C. § 3719, and the Older Americans Act at 42 U.S.C. § 3012(a)(31) and (b)(8) for the types of activities the prize is intended to incentivize.