Source: https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&ty=HTML&h=L&mc=true&r=SECTION&n=se42.3.425_1603
Timestamp: 2019-11-14 02:21:00
Document Index: 581432562

Matched Legal Cases: ['art 425', '§425', '§425', '§425', '§425', '§425', '§425', '§425', '§425', '§425', '§425']

Title 42 → Chapter IV → Subchapter B → Part 425 → Subpart G → §425.603
Subpart G—Shared Savings and Losses
§425.603 Resetting, adjusting, and updating the benchmark for a subsequent agreement period beginning on or before January 1, 2019.
(b) For second agreement periods beginning in 2016, CMS establishes, adjusts, and updates the rebased historical benchmark in accordance with §425.602(a) and (b) with the following modifications:
(1) Rather than weighting each year of the benchmark using the percentages provided at §425.602(a)(7), each benchmark year is weighted equally.
(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. CMS does all of the following:
(1) Calculates the payment amounts included in Parts A and B fee-for-service claims using a 3-month claims run out with a completion factor. The calculation—
(8) The ACO's benchmark will be adjusted in accordance with §425.118(b) for the addition and removal of ACO participants or ACO providers/suppliers during the term of the agreement period. To adjust the benchmark, CMS does the following:
(10) The historical benchmark is further adjusted at the time of reconciliation for a performance year to account for changes in severity and case mix for newly and continuously assigned beneficiaries using prospective HCC risk scores and demographic factors as described under §§425.604(a)(1) through (3), 425.606(a)(1) through (3), and 425.610(a)(1) through (3).
(1)(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.
(2) Calculates assignable beneficiary expenditures using the payment amounts included in Parts A and B fee-for-service claims with dates of service in the 12-month calendar year for the relevant benchmark or performance year, using a 3-month claims run out with a completion factor. The calculation—
(f) For second or subsequent agreement periods beginning in 2017, 2018, and on January 1, 2019, CMS calculates an ACO's risk adjusted regional expenditures by—
(g) In determining performance for the January 1, 2019 through June 30, 2019 performance year described in §425.609(b) CMS does all of the following:
(1) When adjusting the benchmark using the methodology set forth in paragraph (c)(10) of this section and §425.609(b), CMS adjusts for severity and case mix between BY3 and CY 2019.
(2) When updating the benchmark using the methodology set forth in paragraph (d) of this section and §425.609(b), CMS updates the benchmark based on growth between BY3 and CY 2019.