(ii) An ACO that previously participated in Track 1 under paragraph (a)(1) of this section or a new ACO identified as a re-entering ACO because more than 50 percent of its ACO participants have recent prior experience in a Track 1 ACO may elect to enter its agreement period at any of the levels of risk and potential reward available under paragraphs (a)(4)(i)(A)(2) through (5) of this section. (4) For performance years beginning on or after January 1, 2024. (2) If the amount of shared savings earned by the ACO is revised upward by CMS for any reason, CMS will reduce the redetermined amount of shared savings by the amount of advance investment payments made to the ACO as of the date of the redetermination. (iii) If an ACO does not report any of the ten CMS Web Interface measures or any of the three eCQMs/MIPS CQMs and does not administer a CAHPS for MIPS survey under the APP, the ACO will not meet the quality performance standard or the alternative quality performance standard. (1) In an audit, the ACO will provide beneficiary medical records data if requested by CMS. (i) If any amount of shared savings remains after completely repaying the amount of shared losses owed, the ACO is eligible to receive payment for the remainder of the shared savings. (3) Calculation of Medicare Parts A and B fee-for-service revenue of ACO participants for purposes of calculating the ACO's loss recoupment limit under the BASIC track as specified in 425.605(d). (B) Determine the ACO's regional expenditures as specified under 425.654. (2) Promote patient engagement. (B) Prospective assignment, as described in 425.400(a)(3). (iii) Satisfy all other requirements of this section. (C) Aggregating the weighted county-level shares for all counties in the ACO's regional service area. Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data. (4) If the ACO terminates the participation agreement, the waiver ends on the effective date of termination as specified in the written notification required under 425.220. (iii) The ACO is automatically advanced to Level E pursuant to paragraph (h)(2)(i) of this section. (a) If the initial determination denying an ACO's application to participate in the Shared Savings Program is upheld, the application will remain denied based on the effective date of the original notice of denial. (iii) Otherwise maintain its eligibility to participate in the Shared Savings Program under this part. (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. (ii) For performance years beginning January 1, 2023 and in subsequent years, BASIC track (Levels C through E). (a) General. (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. (2) Provide a procedure to determine whether a conflict of interest exists and set forth a process to address any conflicts that arise. (2) Not be used in a discriminatory manner or for discriminatory purposes. (5) Effect on program calculations. (ii) If the ACO fails to meet either the quality performance standard or the alternative quality performance standard established in 425.512 for the applicable performance year, the shared loss rate is 75 percent. An ACO is automatically advanced to the next level of the BASIC track's glide path at the start of each subsequent performance year of the agreement period, if a higher level of risk and potential reward is available under the BASIC track, except as follows: (i) 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). Medicare Shared Savings Program - Centers for Medicare 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). CMS establishes quality performance measures to assess the quality of care furnished by the ACO. For more information on the Medicare Shared Savings Program, visithttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram, For more information on the proposals for the Medicare Shared Savings Program in the 2023 Physician Fee Schedule proposed rule, visithttps://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2023-medicare-physician-fee-schedule-proposed-rule-medicare-shared-savings-program, View the 2021 Medicare Shared Savings Program Financial and Quality performance results at https://data.cms.gov/medicare-shared-savings-program/performance-year-financial-and-quality-results/data, Get CMS news at cms.gov/newsroom, sign up for CMS news via email and follow CMS on Twitter @CMSgov, CMS News and Media Group (e) Special rules for determining the weights used in the regional adjustment calculation for a re-entering ACO. will also bring you to search results. (3) An ACO that seeks to enter a new participation agreement under the Shared Savings Program and was newly formed after March 23, 2010, as defined in the Antitrust Policy Statement, must agree that CMS can share a copy of its application with the Antitrust Agencies. (ii) Employ its internal assessments of cost and quality of care to improve continuously the ACO's care practices. To qualify for shared savings, an ACO must meet the minimum savings rate requirement established under paragraph (b) of this section, meet the quality performance standard established under 425.512, and otherwise maintain its eligibility to participate in the Shared Savings Program under this part. (v) For the performance year starting on January 1, 2021: (1) 96160 and 96161 (codes for administration of health risk assessment). At 81 FR 38017, June 10, 2016, in 425.610, paragraph (a)(2)(ii), the phrase adjust for changes was removed, and in its place the phrase adjust the benchmark for changes was added, however, the phrase adjust for changes does not appear in this paragraph, so the amendment could not be incorporated. Please do not provide confidential (1) CMS may request the submission of marketing materials and activities at any time. CMS will review the supplemental application information to determine whether an ACO meets the eligibility criteria and other requirements for advance investment payments and will approve or deny the advance investment payment application accordingly. An ACO that meets all the requirements for receiving shared savings payments under the BASIC track, Level E, receives a shared savings payment equal to a percentage of all the savings under the updated benchmark (up to the performance payment limit described in paragraph (d)(1)(v)(B) of this section). (a) ACOs must limit their identifiable data requests to the minimum necessary to accomplish a permitted use of the data. (2) The telehealth services are provided by a physician or practitioner billing under the TIN of an ACO participant in the ACO within 90 days following the date CMS delivers the quarterly exclusion list to the ACO. The ADI drives a weight away from dense, structurally marginalized neighborhoods and cities, particularly where Black, Latino and low-income Asian patients congregate, and we see that disparity, he said. For performance year 2020, the ACO remains in the same level of the BASIC track's glide path that it entered for the July 1, 2019 through December 31, 2019 performance year, unless the ACO chooses to advance more quickly in accordance with 425.226(a)(2)(i). (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. (3) The ability of the ACO to bear the risk of potential losses and to repay any losses to CMS. (4) CMS has sole discretion to determine the time period during which an extreme and uncontrollable circumstance occurred and the percentage of the ACO's assigned beneficiaries residing in the affected areas. (4) The initial determination or revised initial determination of whether an ACO is eligible for shared savings, and the amount of such shared savings, including the initial determination or revised initial determination of the estimated average per capita Medicare expenditures under the ACO for Medicare fee-for-service beneficiaries assigned to the ACO and the average benchmark for the ACO in accordance with section 1899(d) of the Act, as implemented under 425.601, 425.602, 425.603, 425.604, 425.605, 425.606, 425.610, and 425.652. (i) If the 15th day is a weekend or a Federal holiday, then the timeframe is extended until the end of the next business day. (iv) In the case of an ACO that has selected prospective assignment, by the ACO or ACO participant providing each prospectively assigned beneficiary with a standardized written notice at least once during an agreement period in the form and manner specified by CMS. (iv) Identification of key clinical and administrative leadership. At the end of each performance year, an individual with the legal authority to bind the ACO must certify to the best of his or her knowledge, information, and belief. (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. (b) An ACO formed by two or more ACO participants, each of which is identified by a unique TIN, must be a legal entity separate from any of its ACO participants. (B) The ACO must retain a record of all beneficiaries receiving the follow-up communication, and the form and manner in which the communication was made available to the beneficiary. (4) ACO participant TINs and individual eligible professionals who bill under the TIN of an ACO participant cannot earn a Physician Quality Reporting System incentive outside of the Medicare Shared Savings Program. (2) The ACO meets the criteria established for ACOs seeking to renew their agreements under 425.224(b). 49 CFR 172.101 (3) All evidence submitted by the ACO and CMS, in preparation for the reconsideration review will be shared with the other party to the hearing. Program requirements for data submission and certifications. The Accountable Care Organization Participants data presents overview information on ACO participants in the Medicare Shared Savings Program (Shared (B) Identify additional target populations that would benefit from individualized care plans. Centers for Medicare & Medicaid Services, Department of Health and Human Services, https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-425, Shared Savings Program Eligibility Requirements. (2) 99201 through 99215 (codes for office or other outpatient visit for the evaluation and management of a patient). Participation agreement means the written agreement required under 425.208(a) between the ACO and CMS that, along with the regulations in this part, govern the ACO's participation in the Shared Savings Program. (c) For second or subsequent agreement periods beginning in 2017, 2018 and on January 1, 2019, CMS establishes the rebased historical benchmark by determining the per capita Parts A and B fee-for-service expenditures for beneficiaries who would have been assigned to the ACO in any of the 3 most recent years before the agreement period using the certified ACO participant list submitted before the start of the agreement period as required under 425.118. To qualify for shared savings, an ACO must meet the minimum savings rate requirement established under paragraph (b) of this section, meet the minimum quality performance standards established under 425.502, and otherwise maintain its eligibility to participate in the Shared Savings Program under this part. (iii) A process for evaluating the health needs of the ACO's population, including consideration of diversity in its patient populations, and a plan to address the needs of its population. 1 Executive Summary . (iii) The use of equal weights to weight each benchmark year as specified in 425.601(e), and 425.652(c)(2). (5) CMS reserves the right to redesignate a measure as pay for reporting when the measure owner determines the measure no longer aligns with clinical practice or causes patient harm, or when there is a determination under the Quality Payment Program that the measure has undergone a substantive change. (ii) CMS will terminate an ACO's participation agreement under any of the following circumstances: (A) The ACO fails to meet the quality performance standard for 2 consecutive performance years within an agreement period. (5) If an ACO's average per capita Medicare expenditures for the performance year are above its updated benchmark for the year determined as described in paragraph (b)(4) of this section by at least the MLR or negative MSR established for the ACO, CMS will compute a recalculated updated benchmark using the two-way blend described in paragraph (b)(2) of this section. In letters to CMS, provider organizations largely expressed support for the regulator's decision to leverage data to target resources to communities considered socially vulnerable but pushed for the methodology to evolve. Calculation of savings under the one-sided model. The eCFR is displayed with paragraphs split and indented to follow For performance year 2017 and subsequent performance years, the following adjustment is made in calculating the amount of shared losses, after the application of the shared loss rate in paragraph (f) of this section and the loss recoupment limit in paragraph (g) of this section. (7) Weights each year of the benchmark for an ACO's initial agreement period using the following percentages: (8) Adjusts the historical benchmark based on the ACO's regional service area expenditures, making separate calculations for the following populations of beneficiaries: ESRD, disabled, aged/dual eligible Medicare and Medicaid beneficiaries, and aged/non-dual eligible Medicare and Medicaid beneficiaries. (ii) Beneficiary eligibility. (ii) For a new ACO identified as a re-entering ACO, the ACO in which the majority of the new ACO's participants were participating previously entered into a participation agreement for participation in the BASIC track only one time. (2) For the performance year beginning on January 1, 2021. (b) Monitoring ACO avoidance of at-risk beneficiaries. (b) Minimum savings rate (MSR). Establishing, adjusting, and updating the benchmark for an ACO's first agreement period beginning on or before January 1, 2018. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. (ii) Has any months of Part A only or Part B only enrollment. (2) The patients of its HIPAA-covered entity ACO participants or its ACO providers/suppliers as the business associate of these HIPAA covered entities, and the request reflects the minimum data necessary for the ACO to conduct health care operations work that falls within the first or second paragraph of the definition of health care operations at 45 CFR 164.501 on behalf of those participants. (a) An ACO must be a legal entity, formed under applicable State, Federal, or Tribal law, and authorized to conduct business in each State in which it operates for purposes of the following: (1) Receiving and distributing shared savings. (j) January 1, 2019 through June 30, 2019 performance year. ACOs, ACO participants, and ACO providers/suppliers are prohibited from doing the following: (1) Conditioning the participation of ACO participants, ACO providers/suppliers, other individuals or entities performing functions or services related to ACO activities in the ACO on referrals of Federal health care program business that the ACO, its ACO participants, or ACO providers/suppliers or other individuals or entities performing functions or services related to ACO activities know or should know is being (or would be) provided to beneficiaries who are not assigned to the ACO. 425.704 Beneficiary-identifiable claims data. (i) The first window will be the first 12 months used for interim payment calculation. (i) For an ACO that is liable for a pro-rated share of losses under 425.221(b)(2)(ii), the amount of shared losses determined for the performance year during which the termination becomes effective is adjusted according to this paragraph (f)(2). (2) Has any months of Medicare group (private) health plan enrollment. (iii) CMS may deny the request on the basis that the entity is not eligible to be an ACO participant or on the basis of the results of the screening performed under 425.305(a). (4) CMS may deny a waiver request if an ACO fails to submit requested information by the deadlines established by CMS. (7) A savings percentage (based on a comparison of summed expenditures to summed updated benchmark dollars) for the ACO's 18 or 21 month performance year is compared to the ACO's MSR or MLR. An ACO receives two types of advance investment payments: a one-time payment of $250,000 and quarterly payments calculated pursuant to the methodology defined in paragraph (f)(2) of this section. (7) Information about a beneficiary incentive program established under 425.304(c), if applicable, including the following, for each performance year: (i) Total number of beneficiaries who received an incentive payment. It is not an official legal edition of the CFR. The ACO must submit such election, together with revised repayment mechanism documentation, in a form and manner and by a deadline specified by CMS. Certified Electronic Health Record Technology (CEHRT) has the same meaning given this term under 414.1305 of this chapter. 45 et seq.). (6) If, in accordance with 425.226(a)(2)(i), the ACO elects to transition to a higher level of risk and reward available under paragraphs (a)(4)(i)(A)(3) through (5) of this section, then the automatic transition to levels of higher risk and reward specified in paragraph (a)(4)(i)(C)(2) of this section applies to all subsequent performance years of the agreement period. (1) The ACO's performance year assigned beneficiary population identified in paragraph (b)(1) of this section is used to determine the MSR for Track 1 ACOs and the variable MSR/MLR for ACOs in a two-sided model that selected this option at the start of their agreement period. [76 FR 67973, Nov. 2, 2011, as amended at 80 FR 32844, June 9, 2015; 83 FR 68082, Dec. 31, 2018; 87 FR 70249, Nov. 18, 2022]. (iii) The ACO must certify the accuracy of this information. (i) For performance years 2022, 2023, and 2024. (i) An ACO starting a 12-month performance year on January 1, 2019, that terminates its participation agreement with an effective date of termination of June 30, 2019, and that enters a new agreement period beginning on July 1, 2019, is eligible for pro-rated shared savings or liable for pro-rated shared losses for the 6-month period from January 1, 2019, through June 30, 2019, as determined in accordance with 425.609. (a) General. CMS may terminate the participation agreement with an ACO when an ACO, the ACO participants, ACO providers/suppliers or other individuals or entities performing functions or services related to ACO activities fail to comply with any of the requirements of the Shared Savings Program under this part. Newly assigned beneficiary means a beneficiary that is assigned to the ACO in the current performance year who was neither assigned to nor received a primary care service from any of the ACO participants during the assignment window for the most recent prior benchmark or performance year. Displaying title 42, up to date as of 6/26/2023. The ACO governing body must have a conflict of interest policy that applies to members of the governing body. (2) A re-entering ACO is considered to be entering a new agreement period in the Shared Savings Program as follows. Bidenomics Is Working: The Presidents Plan Grows the ACOs identified under paragraph (a)(1)(vi) of this section may request to use the SNF 3-day rule waiver for performance years beginning on July 1, 2019, and in subsequent years. (ii) This calculation considers individually beneficiary identifiable payments made under a demonstration, pilot or time limited program. CMS uses an ACO's prospective HCC risk score to adjust the benchmark for changes in severity and case mix in the assigned beneficiary population between BY3 and the performance year. For agreement periods beginning on January 1, 2024, and in subsequent years, CMS incorporates a fixed projected growth rate determined at the beginning of the ACO's agreement period called the Accountable Care Prospective Trend (ACPT) into the blended update factor described in 425.652(b) when updating an ACO's benchmark for each performance year of the agreement period. The agreements may be submitted in the form and manner set forth in 425.204(c)(6) or as otherwise specified by CMS. (ii) Prospective assignment, as described in 425.400(a)(3). (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. (5) Trends forward expenditures for each benchmark year (BY1 and BY2) to the third benchmark year (BY3) dollars using a blend of national and regional growth rates. (2) An ACO that will participate in a two-sided model must establish one or more of the following repayment mechanisms in an amount and by a deadline specified by CMS in accordance with this section: (i) An escrow account with an insured institution. Adjustments to Shared Savings Program calculations to address the COVID19 pandemic. (1) CMS may use one or more of the methods described in paragraph (a)(2) of this section (as appropriate) to identify trends and patterns suggesting that an ACO has avoided at-risk beneficiaries. An ACO that meets all the requirements for receiving shared savings payments under the BASIC track, Level B, receives a shared savings payment equal to a percentage of all the savings under the updated benchmark (up to the performance payment limit described in paragraph (d)(1)(ii)(B) of this section). (12) G2212 (code for prolonged office or other outpatient visit for the evaluation and management of a patient). An ACO that establishes a beneficiary incentive program must maintain records related to the beneficiary incentive program that include the following: (A) Identification of each beneficiary that received an incentive payment, including beneficiary name and HICN or Medicare beneficiary identifier. Shared savings means a portion of the ACO's performance year Medicare fee-for-service Parts A and B expenditures, below the applicable benchmark, it is eligible to receive payment for from CMS. guide. (1) ACOs, on behalf of eligible professionals who bill under the TIN of an ACO participant, must submit the measures determined under 425.500 using a CMS web interface, to qualify on behalf of their eligible professionals for the Physician Quality Reporting System incentive under the Shared Savings Program. (b) The reconsideration review process under this subpart must not be construed to negate, diminish, or otherwise alter the applicability of existing laws, rules, and regulations or determinations made by other government agencies. (1) General. (a) Acknowledgement of reconsideration review request. (c) The independent CMS official considers the recommendation of the reconsideration official and makes a final agency determination. An ACO is eligible to receive advance investment payments as specified in this section if CMS determines that all of the following criteria are met: (1) The ACO is not a renewing or a re-entering ACO. 425.220 Termination of the participation agreement by the ACO. (iv) CMS calculates an underserved multiplier for the ACO. (ii) ACOs must also submit any other specific identifying information as required by CMS in the application process. Except as provided in paragraph (h) of this section, the percentage is as follows: (i) 50 percent for an ACO that meets the quality performance standard by meeting the criteria specified in 425.512(a)(2) or (a)(5)(i). (ii) The weight used in calculating the regional adjustment to the ACO's historical benchmark as described in 425.601(f), and 425.656(d). (1) Notwithstanding the assignment methodology under paragraph (b) of this section, beneficiaries who designate an ACO professional participating in an ACO as responsible for coordinating their overall care are prospectively assigned to that ACO, regardless of track, annually at the beginning of each benchmark and performance year based on available data at the time assignment lists are determined for the benchmark and performance year. full text search results (iii) The originating site must comply with applicable State licensing requirements. The repayment mechanism applicable to the new agreement period may be the same repayment mechanism currently used by the ACO, provided that the ACO submits documentation establishing that the duration of the existing repayment mechanism has been revised to comply with paragraph (f)(6)(ii) of this section, and the amount of the repayment mechanism complies with paragraph (f)(4) of this section.
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