Source: https://www.law.cornell.edu/cfr/text/42/425.604
Timestamp: 2018-11-14 14:08:14
Document Index: 768649047

Matched Legal Cases: ['art 425', '§ 425', '§ 425', '§ 425', '§ 425', '§ 425', 'art 425', 'arts 414', '§ 425', '§ 425', '§ 425', '§ 425']

42 CFR 425.604 - Calculation of savings under the one-sided model. | US Law | LII / Legal Information Institute
CFR › Title 42 › Chapter IV › Subchapter B › Part 425 › Subpart G › Section 425.604
42 CFR 425.604 - Calculation of savings under the one-sided model.
§ 425.604 Calculation of savings under the one-sided model.
Link to an amendment published at 82 FR 53370, Nov. 15, 2017.
(a)Savings determination. For each performance year, CMS determines whether the estimated average per capita Medicare expenditures under the ACO for Medicare fee-for-service beneficiaries for Parts A and B services are below the applicable updated benchmark determined under § 425.602.
(1)Newly assigned beneficiaries. CMS uses an ACO's HCC prospective risk score to adjust the benchmark for changes in severity and case mix in this population.
(2)Continuously assigned beneficiaries.
(i) CMS uses demographic factors to adjust the benchmark for changes in the continuously assigned population.
(ii) If the prospective HCC risk score is lower in the performance year for this population, CMS will adjust the benchmark for changes in severity and case mix in this population using this lower prospective HCC risk score.
(3) Assigned beneficiary changes in demographics and health status are used to adjust benchmark expenditures as described in § 425.602(a). In adjusting the benchmark for health status and demographic changes CMS makes adjustments for separate categories 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.
(i) For performance years before 2017 to minimize variation from catastrophically large claims, CMS 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 performance year.
(ii) For the 2017 performance year and subsequent performance years, to minimize variation from catastrophically large claims, CMS 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 the applicable performance year for assignable beneficiaries identified for the 12-month calendar year corresponding to the performance year.
(5) CMS uses a 3 month claims run out with a completion factor to calculate an ACO's per capita expenditures for each performance year.
(6) Calculations of the ACO's expenditures will include the payment amounts included in Part A and B fee-for-service claims.
(i) These calculations will exclude indirect medical education (IME) and disproportionate share hospital (DSH) payments.
(ii) These calculations will take into consideration individually beneficiary identifiable payments made under a demonstration, pilot or time limited program.
(7) In order to qualify for a shared savings payment, the ACO's average per capita Medicare expenditures for the performance year must be below the applicable updated benchmark by at least the minimum savings rate established for the ACO under paragraph (b) of this section.
(b)Minimum savings rate (MSR). CMS uses a sliding scale, based on the number of beneficiaries assigned to the ACO under subpart E of this part, to establish the MSR for an ACO participating under the one-sided model. The MSR under the one-sided model for an ACO based on the number of assigned beneficiaries is as follows:
MSR (low end of assigned beneficiaries) (percent)
(high end
of assigned beneficiaries)
5,000-5,999 3.9 3.6
6,000-6,999 3.6 3.4
7,000-7,999 3.4 3.2
8,000-8,999 3.2 3.1
9,000-9,999 3.1 3.0
10,000-14,999 3.0 2.7
15,000-19,999 2.7 2.5
20,000-49,999 2.5 2.2
50,000-59,999 2.2 2.0
60,000 + 2.0
(c)Qualification for shared savings payment. In order to qualify for shared savings, an ACO must meet or exceed its minimum savings rate determined 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.
(d)Final sharing rate. An ACO that meets all the requirements for receiving shared savings payments under the one-sided model will receive a shared savings payment of up to 50 percent of all savings under the updated benchmark, as determined on the basis of its quality performance under § 425.502 of this part (up to the performance payment limit described in paragraph (e)(2) of this section).
(e)Performance payment.
(1) If an ACO qualifies for savings by meeting or exceeding the MSR, the final sharing rate will apply to an ACO's savings on a first dollar basis.
(2) The amount of shared savings an eligible ACO receives under the one-sided model may not exceed 10 percent of its updated benchmark.
(f)Notification of savings. CMS notifies an ACO in writing regarding whether the ACO qualifies for a shared savings payment, and if so, the amount of the payment due.
[ 76 FR 67973, Nov. 2, 2011, as amended at 81 FR 38016, June 10, 2016]
The following are ALL rules, proposed rules, and notices (chronologically) published in the Federal Register relating to 42 CFR Part 425 after this date.
83 FR 41786 - Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations—Pathways to Success
FR Doc. 2018-17101
RIN 0938-AT45
CMS-1701-P
To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on October 16, 2018.
42 CFR Parts 414 and 425
Under the Medicare Shared Savings Program (Shared Savings Program), providers of services and suppliers that participate in an Accountable Care Organization (ACO) continue to receive traditional Medicare fee-for-service (FFS) payments under Parts A and B, but the ACO may be eligible to receive a shared savings payment if it meets specified quality and savings requirements. The policies included in this proposed rule would provide a new direction for the Shared Savings Program by establishing pathways to success through redesigning the participation options available under the program to encourage ACOs to transition to two-sided models (in which they may share in savings and are accountable for repaying shared losses). These proposed policies are designed to increase savings for the Trust Funds and mitigate losses, reduce gaming opportunities, and promote regulatory flexibility and free-market principles. The proposed rule also would provide new tools to support coordination of care across settings and strengthen beneficiary engagement; ensure rigorous benchmarking; promote interoperable electronic health record technology among ACO providers/suppliers; and improve information sharing on opioid use to combat opioid addiction.
82 FR 60912 - Medicare Program; Medicare Shared Savings Program: Extreme and Uncontrollable Circumstances Policies for Performance Year 2017
FR Doc. 2017-27920
RIN 0938-AT51
CMS-1702-IFC
Effective date: These regulations are effective on January 20, 2018. Comment date: To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on February 20, 2018.
This interim final rule with comment period establishes policies for assessing the financial and quality performance of Medicare Shared Savings Program (Shared Savings Program) Accountable Care Organizations (ACOs) affected by extreme and uncontrollable circumstances during performance year 2017, including the applicable quality reporting period for the performance year. Under the Shared Savings Program, providers of services and suppliers that participate in ACOs continue to receive traditional Medicare fee-for-service (FFS) payments under Parts A and B, but the ACO may be eligible to receive a shared savings payment if it meets specified quality and savings requirements. ACOs in performance-based risk agreements may also share in losses. This interim final rule with comment period establishes extreme and uncontrollable circumstances policies for the Shared Savings Program that will apply to ACOs subject to extreme and uncontrollable events, such as Hurricanes Harvey, Irma, and Maria, and the California wildfires, effective for performance year 2017, including the applicable quality data reporting period for the performance year.
81 FR 37950 - Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations—Revised Benchmark Rebasing Methodology, Facilitating Transition to Performance-Based Risk, and Administrative Finality of Financial Calculations
FR Doc. 2016-13651
RIN 0938-AS67
CMS-1644-F
Effective date: The provisions of this final rule are effective on August 9, 2016. Applicability dates: In the SUPPLEMENTARY INFORMATION section of this final rule, we provide a table (Table 1) that lists key changes in this final rule that have an applicability date other than the effective date of this final rule.
Under the Medicare Shared Savings Program (Shared Savings Program), providers of services and suppliers that participate in an Accountable Care Organization (ACO) continue to receive traditional Medicare fee-for-service (FFS) payments under Parts A and B, but the ACO may be eligible to receive a shared savings payment if it meets specified quality and savings requirements. This final rule addresses changes to the Shared Savings Program, including: Modifications to the program&apos;s benchmarking methodology, when resetting (rebasing) the ACO&apos;s benchmark for a second or subsequent agreement period, to encourage ACOs&apos; continued investment in care coordination and quality improvement; an alternative participation option to encourage ACOs to enter performance-based risk arrangements earlier in their participation under the program; and policies for reopening of payment determinations to make corrections after financial calculations have been performed and ACO shared savings and shared losses for a performance year have been determined.
81 FR 5824 - Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations—Revised Benchmark Rebasing Methodology, Facilitating Transition to Performance-Based Risk, and Administrative Finality of Financial Calculations
FR Doc. 2016-01748
CMS-1644-P
To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on March 28, 2016.
Under the Medicare Shared Savings Program (Shared Savings Program), providers of services and suppliers that participate in an Accountable Care Organization (ACO) continue to receive traditional Medicare fee-for-service (FFS) payments under Parts A and B, but the ACO may be eligible to receive a shared savings payment if it meets specified quality and savings requirements. This proposed rule addresses changes to the Shared Savings Program that would modify the program&apos;s benchmark rebasing methodology to encourage ACOs&apos; continued investment in care coordination and quality improvement, and identifies publicly available data to support modeling and analysis of these proposed changes. In addition, it would streamline the methodology used to adjust an ACO&apos;s historical benchmark for changes in its ACO participant composition, offer an alternative participation option to encourage ACOs to enter performance-based risk arrangements earlier in their participation under the program, and establish policies for reopening of payment determinations to make corrections after financial calculations have been performed and ACO shared savings and shared losses for a performance year have been determined.
80 FR 32692 - Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations
FR Doc. 2015-14005
RIN 0938-AS06
CMS-1461-F
Effective Dates: With the exception of the amendments to §§ 425.312, 425.704, and 425.708, the provisions of this final rule are effective on August 3, 2015. The amendments to § 425.312 and § 425.708 are effective November 1, 2015. The amendments to § 425.704 are effective January 1, 2016. Applicability Dates: In the SUPPLEMENTARY INFORMATION section of this final rule, we provide a table (Table 1) that lists key changes in this final rule that have an applicability date other than the effective date of this final rule.
This final rule addresses changes to the Medicare Shared Savings Program including provisions relating to the payment of Accountable Care Organizations participating in the Medicare Shared Savings Program. Under the Medicare Shared Savings Program, providers of services and suppliers that participate in an Accountable Care Organizations continue to receive traditional Medicare fee-for-service payments under Parts A and B, but the Accountable Care Organizations may be eligible to receive a shared savings payment if it meets specified quality and savings requirements.
42 CFR 425.100 — General.
42 CFR 425.800 — Preclusion of Administrative and Judicial Review.
42 CFR 425.608 — Determining First Year Performance for ACOs Beginning April 1 or July 1, 2012.
42 CFR 425.602 — Establishing, Adjusting, and Updating the Benchmark for an ACO's First Agreement Period.
42 CFR 425.600 — Selection of Risk Model.
42 CFR 425.200 — Participation Agreement With CMS.
42 CFR 425.603 — Resetting, Adjusting, and Updating the Benchmark for a Subsequent Agreement Period.
42 CFR 425.315 — Reopening Determinations of ACO Shared Savings or Shared Losses to Correct Financial Reconciliation Calculations.