Welcome to Scribd. Sign in or start your free trial to enjoy unlimited e-books, audiobooks & documents.Find out more
Standard view
Full view
of .
Look up keyword
Like this
0 of .
Results for:
No results containing your search query
P. 1
ACO Rules

ACO Rules

|Views: 8|Likes:
Published by Il Dc

More info:

Published by: Il Dc on Oct 21, 2011
Copyright:Attribution Non-commercial


Read on Scribd mobile: iPhone, iPad and Android.
download as PDF, TXT or read online from Scribd
See more
See less





DEPARTMENT OF HEALTH AND HUMAN SERVICESCenters for Medicare & Medicaid Services42 CFR Part 425[CMS-1345-F]RIN 0938-AQ22Medicare Program; Medicare Shared Savings Program: Accountable Care OrganizationsAGENCY:
Centers for Medicare & Medicaid Services (CMS), HHS.
Final rule.
This final rule implements section 3022 of the Affordable Care Act whichcontains provisions relating to Medicare payments to providers of services and suppliersparticipating in Accountable Care Organizations (ACOs) under the Medicare Shared SavingsProgram. Under these provisions, providers of services and suppliers can continue to receivetraditional Medicare fee-for-service (FFS) payments under Parts A and B, and be eligible foradditional payments if they meet specified quality and savings requirements.
: These regulations are effective on [OFR: Insert 60 days after the date of publication].
Rebecca Weiss, 410-786-8084, Facsimile: (410) 786-8005, E-mail address: aco@cms.hhs.gov.
To assist readers in referencing sections contained in this preamble, we are providing atable of contents.I. BackgroundA. Introduction and Overview of Value-Based PurchasingB. Statutory Basis for the Medicare Shared Savings ProgramC. Overview of the Medicare Shared Savings Program
CMS-1345-F 2D. Public Comments Received on the Proposed RuleE. Reorganization of the Regulations TextII. Provisions of the Proposed Rule, Summary of and Responses to Public Comments, andProvisions of the Final RuleA. DefinitionsB. Eligibility and Governance1. General Requirementsa. Accountability for Beneficiariesb. Agreement Requirementc. Sufficient Number of Primary Care Providers and Beneficiariesd. Identification and Required Reporting on Participating ACO Professionals2. Eligible Participants3. Legal Structure and Governancea. Legal Entityb. Distribution of Shared Savingsc. Governanced. Composition of the Governing Body4. Leadership and Management Structure5. Processes to Promote Evidence-Based Medicine, Patient Engagement, Reporting,Coordination of Care, and Demonstrating Patient-centerednessa. Processes to Promote Evidence-based Medicineb. Processes to Promote Patient Engagementc. Processes to Report on Quality and Cost Measuresd. Processes to Promote Coordination of Care6. Overlap with other CMS Shared Savings Initiativesa. Duplication in Participation in Medicare Shared Savings Programsb. Transition of the Physician Group Practice (PGP) Demonstration Sites into theShared Savings Programc. Overlap with the Center for Medicare & Medicaid Innovation (Innovation Center)Shared Savings ModelsC. Establishing the Agreement with the Secretary1. Options for Start Date of the Performance Year2. Timing and Process for Evaluating Shared Savings3. New Program Standards Established During the Agreement Period4. Managing Significant Changes to the ACO During the Agreement Period5. Coordination with Other Agenciesa. Waivers of CMP, Anti-Kickback, and Physician Self-Referral Lawsb. IRS Guidance Relating to Tax-Exempt Organization Participating in ACOsc. Antitrust Policy Statementd. Coordinating the Shared Savings Program Application with the Antitrust AgenciesD. Provision of Aggregate and Beneficiary Identifiable Data1. Data Sharing2. Sharing Aggregate Data3. Identification of Historically Assigned Beneficiaries4. Sharing Beneficiary Identifiable Claims Data
CMS-1345-F 35. Giving Beneficiaries the Opportunity to Decline Data SharingE. Assignment of Medicare Fee-for-Service Beneficiaries1. Definition of Primary Care Servicesa. Consideration of Physician Specialties in the Assignment Processb. Consideration of Services Furnished by Non-physician Practitioners in theAssignment Processc. Assignment of Beneficiaries to ACOs that Include FQHCs and/or RHCs(1) Identification of Primary Care Services Rendered in FQHCs and RHCs(2) Identification of the Type of Practitioner Providing the Service in an FQHC/RHC(3) Identification of the Physician Specialty for Services in FQHCs and RHCs2. Prospective vs. Retrospective Beneficiary Assignment to Calculate Eligibility forShared Savings3. Majority vs. Plurality Rule for Beneficiary AssignmentF. Quality and Other Reporting Requirements1. Introduction2. Measures to Assess the Quality of Care Furnished by an ACOa. Generalb. Considerations in Selecting Measuresc. Quality Measures for Use in Establishing Quality Performance Standards that ACOsMust Meet for Shared Savings3. Requirements for Quality Measures Data Submission by ACOsa. Generalb. GPRO Web Interfacec. Certified EHR Technology4. Quality Performance Standardsa. Generalb. Performance Scoring(1) Measure Domains and Measures Included in the Domains(2) Methodology for Calculating a Performance Score for each Measure within aDomain(3) Methodology for Calculating a Performance Score for each Domain(4) The Quality Performance Standard Level5. Incorporation of Other Reporting Requirements Related to the PQRS and ElectronicHealth Records Technology Under Section 1848 of the Act6. Aligning ACO Quality Measures with other Laws and RegulationsG. Shared Savings and Losses1. Authority For and Selection of Shared Savings/Losses Model2. Shared Savings and Losses Determinationa. Overview of Shared Savings and Losses Determinationb. Establishing the Benchmark c. Adjusting the Benchmark and Actual Expenditures(1) Adjusting Benchmark and Performance Year Average Per Capita Expenditures forBeneficiary Characteristics(2) Technical Adjustments to the Benchmark and Performance Year Expenditures(a) Impact of IME and DSH(b) Geographic and Other Payment Adjustments

You're Reading a Free Preview

/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->