Title 42, Part 425 — Medicare Shared Savings Program

Basis and scope.

Definitions.

General.

Eligible providers and suppliers.

Legal entity.

Shared governance.

Leadership and management.

Number of ACO professionals and beneficiaries.

Required processes and patient-centeredness criteria.

Participation in other shared savings initiatives.

Agreements with ACO participants and ACO providers/suppliers.

Required reporting of ACO participants and ACO providers/suppliers.

Participation agreement with CMS.

Application procedures.

Content of the application.

Evaluation procedures for applications.

Provisions of participation agreement.

Application of agreement to ACO participants, ACO providers/suppliers, and others.

Changes to program requirements during the agreement period.

Managing changes to the ACO during the agreement period.

Actions prior to termination.

Termination of the participation agreement by CMS.

Termination of the participation agreement by the ACO.

Close-out procedures and payment consequences of early termination.

Eligibility to re-enter the program for agreement periods beginning before July 1, 2019.

Application procedures for renewing ACOs and re-entering ACOs.

Annual participation elections.

Compliance plan.

Program requirements for data submission and certifications.

Beneficiary incentives.

Other program safeguards.

Participant agreement and exclusivity of ACO participants.

Public reporting and transparency.

Marketing requirements.

Beneficiary notifications.

Audits and record retention.

Reopening determinations of ACO shared savings or shared losses to correct financial reconciliation calculations.

Monitoring of ACOs.

General.

Criteria for a beneficiary to be assigned to an ACO.

Basic assignment methodology.

Special assignment conditions for ACOs including FQHCs and RHCs.

Measures to assess the quality of care furnished by an ACO for performance years (or a performance period) beginning on or before January 1, 2020.

Calculating the ACO quality performance score for performance years (or a performance period) beginning on or before January 1, 2020.

Incorporating reporting requirements related to the Physician Quality Reporting System Incentive and Payment Adjustment.

Incorporating reporting requirements related to adoption of certified electronic health record technology.

Incorporating Promoting Interoperability requirements related to the Quality Payment Program for performance years beginning on or after January 1, 2025.

Incorporating quality reporting requirements related to the Quality Payment Program.

Application of the APM Performance Pathway (APP) quality measure set or the APP Plus quality measure set (as applicable) to Shared Savings Program ACOs for performance years beginning on or after January 1, 2021.

Determining the ACO quality performance standard for performance years beginning on or after January 1, 2021.

Selection of risk model.

Establishing, adjusting, and updating the benchmark for agreement periods beginning on or after July 1, 2019, and before January 1, 2024.

Establishing, adjusting, and updating the benchmark for an ACO's first agreement period beginning on or before January 1, 2018.

Resetting, adjusting, and updating the benchmark for a subsequent agreement period beginning on or before January 1, 2019.

Calculation of savings under the one-sided model.

Calculation of shared savings and losses under the BASIC track.

Calculation of shared savings and losses under Track 2.

Determining first year performance for ACOs beginning April 1 or July 1, 2012.

Determining performance for 6-month performance years during CY 2019.

Calculation of shared savings and losses under the ENHANCED track.

Adjustments to Shared Savings Program calculations to address the COVID-19 pandemic.

Waivers of payment rules or other Medicare requirements.

Telehealth services.

§§ 425.614-425.629 [Reserved]

Option to receive advance investment payments.

§§ 425.631-425.639 [Reserved]

Option to receive prepaid shared savings.

§§ 425.641-425.649 [Reserved]

Benchmarking methodology.

Establishing, adjusting, and updating the benchmark for agreement periods beginning on January 1, 2024, and in subsequent years.

Calculating county expenditures and regional expenditures.

Calculating the regional risk score growth cap adjustment factor.

Calculating the regional adjustment to the historical benchmark.

Calculating the prior savings adjustment to the historical benchmark.

Calculating risk scores used in Shared Savings Program benchmark calculations.

Accountable Care Prospective Trend (ACPT).

[Reserved]

Calculating the population adjustment to the historical benchmark.

[Reserved]

Adjustments to mitigate the impact of significant, anomalous, and highly suspect billing activity on Shared Savings Program financial calculations involving calendar year 2023.

Adjustments to mitigate the impact of significant, anomalous, and highly suspect billing activity on Shared Savings Program financial calculations involving calendar year 2024 or subsequent calendar years.

Accounting for the impact of improper payments on Shared Savings Program financial calculations.

General rules.

Aggregate reports.

Beneficiary-identifiable claims data.

Minimum necessary data.

Beneficiaries may decline claims data sharing.

Data use agreement.

Preclusion of administrative and judicial review.

Request for review.

Reconsideration review process.

On-the-record review of reconsideration official's recommendation by independent CMS official.

Effect of independent CMS official's decision.

Effective date of decision.