§ 425.655 Calculating the regional risk score growth cap adjustment factor. ( a ) *General.* This section describes the methodology for calculating the regional risk score growth cap adjustment factor that will be applied to the regional growth rate component of the three-way blend used to update the historical benchmark as described in § 425.652(b) for agreement periods beginning on January 1, 2024, and in subsequent years.
( b ) *Calculating county risk scores.* CMS does all of the following to determine county prospective HCC and demographic risk scores for use in calculating the ACO's regional risk scores: ( 1 ) Determines average county prospective HCC and demographic risk scores for the assignable population of beneficiaries in each county in the ACO's regional service area. The assignable population of beneficiaries is identified for the relevant benchmark or performance year using the assignment window or expanded window for assignment that is consistent with the beneficiary assignment methodology selected by the ACO for the performance year according to § 425.400(a)(4)(ii).
( 2 ) Makes separate risk score calculations for each of the following populations of beneficiaries: ( i ) ESRD.
( ii ) Disabled.
( iii ) Aged/dual eligible Medicare and Medicaid beneficiaries.
( iv ) Aged/non-dual eligible Medicare and Medicaid beneficiaries.
( c ) *Calculating regional risk scores.* CMS calculates an ACO's regional prospective HCC and demographic risk scores by: ( 1 ) Weighting the county-level risk scores determined under paragraph (b) of this section according to the ACO's proportion of assigned beneficiaries in the county, determined by the number of the ACO's assigned beneficiaries in the applicable population (according to Medicare enrollment type) residing in the county in relation to the ACO's total number of assigned beneficiaries in the applicable population (according to Medicare enrollment type) for the relevant benchmark or performance year for each of the following populations of beneficiaries: ( i ) ESRD.
( ii ) Disabled.
( iii ) Aged/dual eligible Medicare and Medicaid beneficiaries.
( iv ) Aged/non-dual eligible Medicare and Medicaid beneficiaries.
( 2 ) Aggregating the values determined under paragraph (c)(1) of this section for each population of beneficiaries (according to Medicare enrollment type) across all counties within the ACO's regional service area.
( d ) *Determining aggregate growth in regional risk scores.* CMS determines aggregate growth in regional prospective HCC and demographic risk scores by: ( 1 ) Determining growth in regional prospective HCC and demographic risk scores determined in paragraph (c) of this section (expressed as a ratio of the performance year regional risk score to the BY3 regional risk score) for each of the following populations of beneficiaries: ( i ) ESRD.
( ii ) Disabled.
( iii ) Aged/dual eligible Medicare and Medicaid beneficiaries.
( iv ) Aged/non-dual eligible Medicare and Medicaid beneficiaries.
( 2 ) Determines the aggregate growth in regional risk scores by calculating a weighted average of the growth in regional prospective HCC risk scores or demographic risk scores, as applicable, across the populations described in paragraph (d)(1) of this section. When calculating the weighted average growth in prospective HCC risk scores or demographic risk scores, as applicable, the weight applied to the growth in risk scores for each Medicare enrollment type is equal to the product of the ACO's regionally adjusted historical benchmark expenditures for that enrollment type and the ACO's performance year assigned beneficiary person years for that enrollment type.
( e ) *Determining the cap on regional risk score growth.* CMS determines the cap on regional prospective HCC risk score growth by: ( 1 ) Computing the sum of the aggregate growth in regional demographic risk scores as determined in paragraph (d)(2) of this section and 3 percentage points.
( 2 ) Calculating the ACO's aggregate market share by calculating the weighted average of the share of assignable beneficiaries in the ACO's regional service area that are assigned to the ACO for the performance year as determined in § 425.652(b)(2)(iv) across the populations described in § 425.652(b)(1). In calculating this weighted average, the weight applied to the share for each Medicare enrollment type is equal to the ACO's performance year assigned beneficiary person years for that enrollment type.
( 3 ) Adding to the sum computed in paragraph (e)(1) of this section an amount equal to the product of: ( i ) The ACO's aggregate market share as determined in paragraph (e)(2) of this section.
( ii ) The difference between the aggregate growth in regional prospective HCC risk scores as determined in paragraph (d)(2) of this section and the sum determined in paragraph (e)(1) of this section. This difference is subject to a floor of zero.
( f ) *Determining the regional risk score growth cap adjustment factor.* CMS determines the regional risk score growth cap adjustment factor for each Medicare enrollment type to be applied in calculating the regional growth rate described in § 425.652(b) by comparing the aggregate growth in regional prospective HCC risk scores determined in paragraph (d)(2) of this section and, if applicable, the growth in regional prospective HCC risk scores for individual Medicare enrollment types as determined in paragraph (d)(1) of this section with the cap determined in paragraph (e) of this section. ( 1 ) If the aggregate growth in regional prospective HCC risk scores determined in paragraph (d)(2) of this section does not exceed the cap on regional risk score growth determined in paragraph (e) of this section, CMS will set the regional risk score growth cap adjustment factor equal to 1 for each of the following populations of beneficiaries: ( i ) ESRD.
( ii ) Disabled.
( iii ) Aged/dual eligible Medicare and Medicaid beneficiaries.
( iv ) Aged/non-dual eligible Medicare and Medicaid beneficiaries.
( 2 ) If the aggregate growth in regional prospective HCC risk scores determined in paragraph (d)(2) of this section exceeds the cap determined in paragraph (e) of this section, CMS will compare the growth in regional prospective HCC risk scores for each Medicare enrollment type as determined in paragraph (d)(1) of this section with the cap on regional risk score growth determined in paragraph (e) of this section. ( i ) If the growth in regional prospective HCC risk scores for the enrollment type determined in paragraph (d)(1) of this section does not exceed the cap on regional risk score growth determined in paragraph (e) of this section, CMS will set the regional risk score growth cap adjustment factor for that enrollment type equal to 1.
( ii ) If the growth in regional prospective HCC risk scores determined in paragraph (d)(1) for the enrollment type exceeds the cap on regional risk score growth determined in paragraph (e) of this section, CMS will set the regional risk score growth cap adjustment factor for that enrollment type equal to the growth in regional prospective HCC risk scores for the enrollment type determined in paragraph (d)(1) of this section divided by the cap on regional risk score growth determined in paragraph (e) of this section.
[88 FR 79549, Nov. 16, 2023]