(4) Lives in the United States or U.S. territories and possessions, based on the most recent available data in our beneficiary records regarding the beneficiary's residence at the end of the assignment window. 425.611 Adjustments to Shared Savings Program calculations to address the COVID19 pandemic. A voluntary election by an ACO under this paragraph must be made in the form and manner and by a deadline established by CMS. An ACO or its ACO participants shall notify assigned beneficiaries of the availability of the beneficiary incentive program in accordance with 425.312(b). (1) To update the benchmark, CMS makes separate calculations for expenditure categories for each of the following populations of beneficiaries: (iii) Aged/dual eligible Medicare and Medicaid beneficiaries. (A) Determines the difference between the average per capita amount of expenditures for the ACO's regional service area as specified under paragraph (c)(9)(i) of this section and the average per capita amount of the ACO's rebased historical benchmark determined under paragraphs (c)(1) through)(8) of this section, for each of the following populations of beneficiaries: (B) Applies a percentage, determined as follows: (1) The first time an ACO's benchmark is rebased using the methodology described under paragraph (c) of this section, CMS calculates the regional adjustment as follows: (i) Using 35 percent of the difference between the average per capita amount of expenditures for the ACO's regional service area and the average per capita amount of the ACO's rebased historical benchmark, if the ACO is determined to have lower spending than the ACO's regional service area; (ii) Using 25 percent of the difference between the average per capita amount of expenditures for the ACO's regional service area and the average per capita amount of the ACO's rebased historical benchmark, if the ACO is determined to have higher spending than the ACO's regional service area. Eligibility to re-enter the program for agreement periods beginning before July 1, 2019. 1 et seq. (2) National growth rates are computed using CMS Office of the Actuary national Medicare expenditure data for BY3 and the performance year for assignable beneficiaries identified for the 12-month calendar year corresponding to each year. (ii) If the ACO fails to meet the quality performance standard established in 425.512, the shared loss rate is 75 percent. (v) CMS does not pay a facility fee when the originating site is the beneficiary's home. (B) If the proportion determined in accordance with paragraph (b)(2)(iv)(A) of this section is lower than 20 percent, the ACO is ineligible for health equity adjustment bonus points. (v) Beneficiary engagement and shared decision-making that takes into account the beneficiaries' unique needs, preferences, values, and priorities; (vi) Written standards in place for beneficiary access and communication, and a process in place for beneficiaries to access their medical record. (ii) The ACO is a low revenue ACO as defined in 425.20 as determined at the time of financial reconciliation for the performance year. (9) The agreement must require completion of a close-out process upon termination or expiration of the agreement that requires the ACO participant to furnish all data necessary to complete the annual assessment of the ACO's quality of care and addresses other relevant matters. (A) An ACO under a two-sided model that terminates its participation agreement under 425.220 with an effective date of termination after June 30th of a 12-month performance year is liable for a pro-rated share of any shared losses determined for the performance year during which the termination becomes effective. The Centers for Medicare & Medicaid Services (CMS) recognizes that the design and operational features of a waiver program will vary depending on the specific needs of the target population, the resources available to the state, service delivery system structure, state goals and objectives, and other factors. (B) The ACO has completed all close-out procedures by the deadline specified by CMS. For agreement periods beginning before July 1, 2019, an ACO in Track 2 operates under a two-sided model (as described under 425.606), sharing both savings and losses with the Medicare program for the agreement period. (ii) Services furnished by a CCN with a deactivated enrollment status that is enrolled under an ACO participant at the start of a performance year will be considered in determining beneficiary assignment to the ACO for the applicable performance year or benchmark year. (12) Multispecialty clinic or group practice. 425.206 Evaluation procedures for applications. (ii) For ACOs under prospective assignment, (A) Medicare fee-for-service beneficiaries are prospectively assigned to the ACO based on the beneficiary's use of primary care services in the most recent 12 months for which data are available; and. (i) For agreement periods beginning before January 1, 2024: (A) Positive adjustments in prospective HCC risk scores are subject to a cap of 3 percent. (2) When updating the benchmark using the methodology set forth in paragraph (b) of this section and 425.609(c), CMS updates the benchmark based on growth between BY3 and CY 2019. 425.218 Termination of the participation agreement by CMS. Upon such a request, the evidence to be submitted must include, without limitation, sample or form agreements and, in the case of ACO participant agreements, the first and signature page(s) of each executed ACO participant agreement. (a) Calculating county expenditures. (i) Except as specified in paragraph (a)(2) of this section, CMS designates the quality performance standard as the ACO reporting quality data via the APP established under 414.1367 of this subchapter, according to the method of submission established by CMS and achieving a quality performance score that is equivalent to or higher than the 30th percentile across all MIPS Quality performance category scores, excluding entities/providers eligible for facility-based scoring. (a) Establishing a quality performance standard. (10) 99439 (code for non-complex chronic care management). (iii) Qualifying service. FAR). (3) Caps the per capita dollar amount for each Medicare enrollment type (ESRD, disabled, aged/dual eligible Medicare and Medicaid beneficiaries, aged/non-dual eligible Medicare and Medicaid beneficiaries) calculated under paragraph (c)(2) of this section at a dollar amount equal to a percentage of national per capita expenditures for Parts A and B services under the original Medicare fee-for-service program in BY3 for assignable beneficiaries in that enrollment type identified for the 12-month calendar year corresponding to BY3 using data from the CMS Office of the Actuary. (2) The MLR is equal to the negative MSR. (5) After the repayment mechanism has been used to repay any portion of shared losses owed to CMS, the ACO must replenish the amount of funds available through the repayment mechanism within 90 days. An ACO that meets all the requirements for receiving shared savings payments under Track 1 will receive a shared savings payment of 50 percent of all the savings under the updated benchmark (up to the performance payment limit described in paragraph (e)(2) of this section). (3) The third or subsequent time that an ACO's benchmark is rebased using the methodology described under paragraph (c) of this section, CMS calculates the regional adjustment to the historical benchmark using 70 percent of the difference between the average per capita amount of expenditures for the ACO's regional service area and the average per capita amount of the ACO's rebased historical benchmark, unless the Secretary determines a lower weight should be applied. (5) For eligible professionals subject to the 2015 Physician Quality Reporting System payment adjustment under the Medicare Shared Savings Program, the Medicare Part B Physician Fee Schedule amount for covered professional services furnished during the program year is equal to the applicable percent of the Medicare Part B Physician Fee Schedule amount that would otherwise apply to such services under section 1848 of the Act. For performance years beginning on July 1, 2019 and for subsequent performance years, an ACO that is participating under Track 2, Levels C, D, or E of the BASIC track, or the ENHANCED track may, in accordance with this section, establish a beneficiary incentive program to provide monetary incentive payments to Medicare fee-for-service beneficiaries who receive a qualifying service. (ii) A description, or documents sufficient to describe, how the ACO will implement the required processes and patient-centeredness criteria under 425.112, including descriptions of the remedial processes and penalties (including the potential for expulsion) that will apply if an ACO participant or an ACO provider/supplier fails to comply with and implement these processes. (1) If an ACO qualifies for savings by meeting or exceeding the MSR, or as provided in paragraph (h) of this section, the final sharing rate specified in paragraph (d)(1)(i)(A) of this section applies to an ACO's savings on a first dollar basis. (3) Other initiatives involving two-sided risk as may be specified by CMS. (4) Calculation of total Medicare Parts A and B fee-for-service revenue of ACO participants and total Medicare Parts A and B fee-for-service expenditures for the ACO's assigned beneficiaries for purposes of identifying whether an ACO is a high revenue ACO or low revenue ACO, as defined under 425.20, determining an ACO's eligibility for participation options according to 425.600(d), and determining an ACO's eligibility to receive advance investment payments according to 425.630. (d) Update of Medicare enrollment information. (iv) In determining the quality performance score for an ACO affected by extreme and uncontrollable circumstances as described in paragraphs (c)(3)(ii) and (iii) of this section. [76 FR 67973, Nov. 2, 2011, as amended at 80 FR 32833, June 9, 2015; 80 FR 71385, Nov. 16, 2015; 81 FR 38013, June 10, 2016; 82 FR 53368, Nov. 15, 2017; 83 FR 60092, Nov. 23, 2018; 83 FR 68062, Dec. 31, 2018; 87 FR 70232, Nov. 18, 2022]. (ii) The ACO's legal entity is located in an area identified under the Quality Payment Program as being affected by an extreme and uncontrollable circumstance. (a) ACOs, ACO participants, and ACO providers/suppliers are encouraged to develop a robust EHR infrastructure. 425.508 Incorporating quality reporting requirements related to the Quality Payment Program. (iii) A new ACO identified as a re-entering ACO enters the program in an agreement period that is determined based on the prior participation of the ACO in which the majority of the new ACO's participants were participating. (d) Monitoring and termination of waivers. (ii) For performance year 2024 and subsequent performance years, the ACO's minimum quality performance score is set to the equivalent of the 40th percentile MIPS Quality performance category score across all MIPS Quality performance category scores, excluding entities/providers eligible for facility-based scoring, for the relevant performance year. 425.210 Application of agreement to ACO participants, ACO providers/suppliers, and others. Shared savings or shared losses for the January 1, 2019 through June 30, 2019 performance year are calculated as described in 425.609. (c) Approval of public reporting information. If the ACO reenters the program under the one-sided model, the ACO will be considered to be in the same agreement period under the one-sided model as it was at the time of termination. (4) Aged/non-dual eligible for Medicare and Medicaid. (3) Weighting the aggregate expenditure values determined for each population of beneficiaries (according to Medicare enrollment type) under paragraph (f)(2) of this section by a weight reflecting the proportion of the ACO's overall beneficiary population in the applicable Medicare enrollment type for the relevant benchmark or performance year. (4) The governing body members may serve in a similar or complementary manner for an ACO participant. (iv) Determining the flat dollar equivalent of the projected absolute amount of growth in national per capita expenditures for Parts A and B services under the original Medicare fee-for-service program for assignable beneficiaries, for purposes of updating the ACO's historical benchmark according to 425.602(b)(2). Subpart DProgram Requirements and Beneficiary Protections. (2) For negative adjustments, the per capita dollar amount for a Medicare enrollment type is capped at negative 5 percent of the national per capita expenditure amount for the enrollment type for BY3. Close-out procedures and payment consequences of early termination. Medicare Shared Savings Program (iii) CMS identifies a program integrity issue affecting the ACO's use of the waiver. (iii) If a CCN enrolled under the TIN of an ACO participant at the start of the performance year enrolls under a different TIN during a performance year, CMS will continue to treat services billed by the CCN as services furnished by the ACO participant it was enrolled under at the start of the performance year for purposes of determining beneficiary assignment to the ACO for the applicable performance year. (c) The independent CMS official considers the recommendation of the reconsideration official and makes a final agency determination. (1) If an ACO qualifies for savings by meeting or exceeding the MSR, or as provided in paragraph (h) of this section, the final sharing rate specified in paragraph (d)(1)(iii)(A) of this section applies to an ACO's savings on a first dollar basis. Regulation Y Number of ACO professionals and beneficiaries. [81 FR 38014, June 10, 2016, as amended at 82 FR 53370, Nov. 15, 2017; 83 FR 60094, Nov. 23, 2018; 83 FR 68074, Dec. 31, 2018; 85 FR 85042, Dec. 28, 2020]. (ii) Discharges for acute care inpatient services for treatment of COVID19 from facilities that are not paid under the inpatient prospective payment system, such as CAHs, when the date of discharge occurs within the Public Health Emergency as defined in 400.200 of this chapter. (i) An ACO must submit to CMS a request to add an entity and its Medicare enrolled TIN to its ACO participant list. (A) If the recalculated repayment mechanism amount exceeds the existing repayment mechanism amount by at least $1,000,000, CMS notifies the ACO in writing that the amount of its repayment mechanism must be increased to the recalculated repayment mechanism amount. (v) For the performance year starting on January 1, 2021: (1) 96160 and 96161 (codes for administration of health risk assessment). (i) ACOs that demonstrate quality improvement on established quality measures from year to year will be eligible for up to 4 bonus points per domain. Changes to program requirements during the agreement period. WebThe Centers for Medicare & Medicaid Services (CMS) recognizes that the design and operational features of a waiver program will vary depending on the specific needs of (1) In order to obtain a determination regarding whether it meets the requirements to participate in the Shared Savings Program, the ACO must submit a complete application in the form and manner and by the deadline specified by CMS. Program Requirements and Beneficiary Protections. The three eCQMs/MIPS CQMs and the CAHPS for MIPS survey. (2) CMS adds the points earned for the individual measures within the domain and divides by the total points available for the domain to determine the domain score. (i) For agreement periods beginning before 2017, (A) Truncates an assigned beneficiary's total annual Parts A and B fee-for-service per capita expenditures at the 99th percentile of national Medicare fee-for-service expenditures as determined for each benchmark year in order to minimize variation from catastrophically large claims; and. CMS may immediately terminate an ACO's advance investment payments without taking any of the pre-termination actions set forth in 425.216. (4) Agreement to validate the eligibility of a beneficiary to receive covered SNF services in accordance with the waiver prior to admission. An ACO that does not meet the minimum savings rate requirement established under paragraph (b) of this section but meets the other criteria described in paragraphs (c)(2)(ii) and (iii) of this section may qualify for a shared savings payment as provided in this paragraph. WebA federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. (B) Expenditures calculated in paragraph (c)(3)(ii)(A) of this section are compared to the ACO's updated benchmark determined according to paragraph (c)(3)(i) of this section. For agreement periods (2) In its request for these data, the ACO must certify that it is seeking the following information: (i) As a HIPAA-covered entity, and the request reflects the minimum data necessary for the ACO to conduct its own health care operations work that falls within the first or second paragraph of the definition of health care operations at 45 CFR 164.501. (4) The national and regional growth rates are blended together by taking a weighted average of the two. [83 FR 68071, Dec. 31, 2018, as amended at 85 FR 85042, Dec. 28, 2020; 87 FR 70237, Nov. 18, 2022]. (iii) A PACE program under section 1894 of the Act. (4) Aged/non-dual eligible Medicare and Medicaid beneficiaries. (12) 99495 and 99496 (codes for transitional care management services). (vi) For performance year 2023, an ACO in Level A under paragraph (a)(4)(i)(A)(1) of this section or in Level B under paragraph (a)(4)(i)(A)(2) of this section may elect to remain in the same level of the BASIC track's glide path in which it participated during performance year 2022, for the remainder of the agreement period, unless the ACO elects to transition to a higher level of risk and potential reward within the BASIC track's glide path as provided in 425.226(a)(2)(i). (B) For a new ACO identified as a re-entering ACO, CMS considers the weight previously applied to calculate the regional adjustment to the benchmark under 425.603(c)(9) in its most recent prior agreement period of the ACO in which the majority of the new ACO's participants were participating previously. [80 FR 32839, June 9, 2015, as amended at 83 FR 60092, Nov. 23, 2018; 83 FR 68064, Dec. 31, 2018]. (2) The ACO governing body must include a Medicare beneficiary who, (iii) Does not have a conflict of interest with the ACO; and. (2) Requiring that beneficiaries be referred only to ACO participants or ACO providers/suppliers within the ACO or to any other provider or supplier, except that the prohibition does not apply to referrals made by employees or contractors who are operating within the scope of their employment or contractual arrangement to the employer or contracting entity, provided that the employees and contractors remain free to make referrals without restriction or limitation if the beneficiary expresses a preference for a different provider, practitioner, or supplier; the beneficiary's insurer determines the provider, practitioner, or supplier; or the referral is not in the beneficiary's best medical interests in the judgment of the referring party. (1) The ACO must submit a CAP for CMS approval by the deadline indicated on the notice of violation. 425.512 Determining the ACO quality performance standard for performance years beginning on or after January 1, 2021. (c) The use of identifiers and claims data will be limited to developing processes and engaging in appropriate activities related to coordinating care and improving the quality and efficiency of care that are applied uniformly to all Medicare beneficiaries with primary care services at the ACO, and that these data will not be used to reduce, limit or restrict care for specific beneficiaries. (c) For agreement periods beginning before July 1, 2019, an ACO experiencing a net loss during a previous agreement period may reapply to participate under the conditions in 425.202(a), except the ACO must also identify in its application the cause(s) for the net loss and specify what safeguards are in place to enable the ACO to potentially achieve savings in its next agreement period. (i) The ACO participant list finalized for the first performance year of the ACO's agreement period beginning on July 1, 2019, is used to determine the quality reporting samples for the 2019 reporting year for the following ACOs: (A) An ACO that extends its participation agreement for a 6-month performance year from January 1, 2019, through June 30, 2019, under 425.200(b)(2)(ii)(B), and enters a new agreement period beginning on July 1, 2019. [76 FR 67973, Nov. 2, 2011, as amended at 80 FR 32840, June 9, 2015; 81 FR 80559, Nov. 15, 2016; 83 FR 68069, Dec. 31, 2018; 85 FR 85039, Dec. 28, 2020; 87 FR 70233, Nov. 18, 2022]. Shared savings or shared losses for the July 1, 2019 through December 31, 2019 performance year are calculated as described in 425.609. (c) Application procedure. (c) Clinical management and oversight must be managed by a senior-level medical director. (i) An ACO whose participation agreement expired without having been renewed re-enters the program under the next consecutive agreement period in the Shared Savings Program; (ii) An ACO whose participation agreement was terminated under 425.218 or 425.220 re-enters the program at the start of the same agreement period in which it was participating at the time of termination from the Shared Savings Program, beginning with the first performance year of that agreement period; or. [76 FR 67973, Nov. 2, 2011, as amended at 80 FR 32845, June 9, 2015]. (2) That the beneficiary incentive program meets all applicable requirements. (b) An ACO that requests a reconsideration review for termination will remain operational throughout the review process. The percentage is as follows: (i) 75 percent for an ACO that meets the quality performance standard by meeting the criteria specified in 425.512(a)(2) or (a)(5)(i). (b) Minimum savings rate (MSR). Before the start of a performance year, an ACO may make elections related to its participation in the Shared Savings Program, as specified in this section, effective at the start of the applicable performance year and for the remaining years of the agreement period, unless superseded by a later election in accordance with this section. (9) G2012 and G2252 (codes for virtual check-in). (2) Mechanisms for identifying and addressing compliance problems related to the ACO's operations and performance. Effect of independent CMS official's decision. (2) Determining growth rates based on expenditures for counties in the ACO's regional service area calculated under paragraphs (e) and (f) of this section, for the performance year compared to BY3 for each of the following populations of beneficiaries: (3) Updating the benchmark by making separate calculations for each of the following populations of beneficiaries: (e) For second or subsequent agreement periods beginning in 2017, 2018 and on January 1, 2019, CMS does all of the following to determine risk adjusted county fee-for-service expenditures for use in calculating the ACO's regional fee-for-service expenditures: (i) Determines average county fee-for-service expenditures based on expenditures for the assignable population of beneficiaries in each county, where assignable beneficiaries are identified for the 12-month calendar year corresponding to the relevant benchmark or performance year. (b) In those instances where there are changes in law or regulations, the ACO will be required to submit to CMS for review and approval, as a supplement to its original application, an explanation detailing how it will modify its processes to address these changes in law or regulations. (E) For an ACO responsible for shared losses under paragraph (b)(3)(ii)(C)(3) of this section, (1) The shared loss rate, determined based on the track the ACO is participating under during the performance year starting on January 1, 2019 ( 425.606 or 425.610), is applied to all losses under the updated benchmark specified under paragraph (b)(3)(i) of this section, not to exceed the loss recoupment limit for the ACO based on its track; and. (5) The offset factor described in paragraph (c)(4) of this section is subject to a minimum value of zero (representing no offset to the negative regional adjustment) and a maximum value of 1 (representing a full offset to the negative regional adjustment). (E) For an ACO responsible for shared losses under paragraph (c)(3)(ii)(C)(3) of this section, (1) The shared loss rate, determined based on the track the ACO is participating under during the performance year starting on July 1, 2019 ( 425.605 or 425.610), is applied to all losses under the updated benchmark specified under paragraph (c)(3)(i) of this section, not to exceed the loss recoupment limit for the ACO based on its track; and. (C) The ACO has satisfied the criteria for sharing in savings for the performance year. (i) Except as specified in paragraph (a)(2) of this section, CMS designates the quality performance standard as the ACO reporting quality data via the APP established under 414.1367 of this subchapter according to the method of submission established by CMS and either: (A) Achieving a health equity adjusted quality performance score that is equivalent to or higher than the 30th percentile across all MIPS Quality performance category scores, excluding entities/providers eligible for facility-based scoring, or. (4) Shared savings and losses information, including the following: (i) Amount of any payment of shared savings received by the ACO or shared losses owed to CMS. Under the BASIC track's glide path, the level of risk and potential reward phases in over the course of the agreement period in the following order: (1) Level A. (5) A requirement for the ACO to report probable violations of law to an appropriate law enforcement agency. This section applies to ACOs in agreement periods beginning on July 1, 2019, and in subsequent years. An ACO in the ENHANCED track operates under a two-sided model (as described under 425.610), sharing both savings and losses with the Medicare program for the agreement period. The weight applied to the, (i) National growth rate is calculated as the share of assignable beneficiaries in the ACO's regional service area that are assigned to the ACO for the applicable performance year as specified in paragraph (a)(5)(v) of this section; and. None of the provisions of this part limit or restrict OIG's authority to audit, evaluate, investigate, or inspect the ACO, its ACO participants, its ACO providers/suppliers and other individuals or entities performing functions or services related to ACO activities. We are encouraged and inspired by five consecutive years of savings and quality improvement, said Meena Seshamani, MD, PhD, CMS Deputy Administrator and Director of the Center for Medicare. (b) Updating the benchmark. (ii) CMS applies a step-wise process based on the beneficiary's utilization of primary care services provided under Title XVIII by a physician who is an ACO professional during each performance year for which shared savings are to be determined and, with respect to ACOs participating in a 6-month performance year during CY 2019, during the entirety of CY 2019 as specified in 425.609. (C) Adjusts for differences in severity and case mix between the ACO's assigned beneficiary population and the assignable beneficiary population for the ACO's regional service area identified for the 12-month calendar year that corresponds to BY3. (f) If an ACO requests beneficiary identifiable information, compliance with the terms of the data use agreement described in 425.710 is a condition of an ACO's participation in the Shared Savings Program. (2) The ACO structure is so different from the initially approved ACO that it must terminate its participation agreement and submit a new application for participation. (g) Recoupment and recovery of advance investment payments, and notice of bankruptcy.
