(a) Health equity plans. (1) The TEAM participant may voluntarily submit a health equity plan to CMS for each performance year that includes the elements specified in paragraph (a)(2) of this section, in a form and manner and by the date specified by CMS.

(2) Health equity plans must include the following elements:

(i) Identifies health disparities in the TEAM participant's population of TEAM beneficiaries.

(ii) Identifies health equity goals and describes how the TEAM participant uses the health equity goals to monitor and evaluate progress in reducing the identified health disparities.

(iii) Describes the health equity plan intervention strategy.

(iv) Identifies health equity plan performance measure(s), the data sources used to construct the performance measures, and an approach to monitor and evaluate the measures.

(b) Health-related social needs screening and reporting. (1) For all performance years, the TEAM participant may voluntarily submit aggregated health-related social needs screening and screened-positive data in a form and manner and by the dates specified by CMS. The health-related social needs screening and reporting must include the elements specified in paragraph (a)(2) of this section.

(2) CMS uses the following measures from the Hospital Inpatient Quality Reporting Program for the TEAM participants who opt to voluntarily submit aggregated health-related social needs screening and screened-positive data.

(i) Screening for Social Drivers of Health (SDOH-1; CMIT ID #1664).

(ii) Screen Positive Rate for Social Drivers of Health (SDOH-2; CMIT ID #1662).

(3) For all performance years, TEAM participants that voluntarily submit data health-related social needs screening and screened-positive data as specified in paragraphs (b)(1) and (2) of this section may voluntarily submit information on referral policies and procedures for beneficiaries that screen positive for health-related social needs in a form and manner and by dates specified by CMS.

(c) Demographic data collection and reporting. For all performance years, the TEAM participant may voluntarily collect and submit to CMS, in a form and manner and by the dates specified by CMS, demographic data of TEAM beneficiaries that are willing to share demographic data elements with the TEAM participant and CMS.