Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program are significantly intertwined with the Centers for Medicare & Medicaid Services (CMS) Quality Payment Program (QPP). Understanding this relationship is crucial for ACOs aiming to deliver high-quality care and achieve financial success within value-based care models. This guide provides comprehensive information on how ACOs engage with quality performance standards and reporting mechanisms under the QPP.
Understanding Program Participation in the Shared Savings Program
The Shared Savings Program encourages groups of doctors, hospitals, and other healthcare providers to come together voluntarily to give coordinated high-quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending healthcare dollars more wisely, it may share in the savings it achieves for the Medicare program.
Program Participation Details
ACOs commit to participating in the Shared Savings Program for a minimum of five years, referred to as the agreement period. This period is further divided into performance years, each with its operational cycle. Organizations can choose between two tracks: the BASIC track, offering a glide path with incremental risk progression, and the ENHANCED track, which involves higher risk but also greater potential rewards. The BASIC track allows ACOs to start under a one-sided model and gradually move towards increased risk-sharing arrangements.
For detailed information on participation options, refer to the About the Program webpage.
Throughout their agreement period, ACOs are expected to:
- Coordinate patient care, rigorously measure and enhance quality of services, and transparently report performance outcomes.
- Prepare diligently for each upcoming performance year by updating contact information in CMS systems, maintaining accurate ACO Participant and Skilled Nursing Facility (SNF) Affiliate lists, and completing the mandatory Annual Certification process.
- Receive annual feedback on their financial and quality performance.
Provider Participation Requirements
Participation in the Shared Savings Program necessitates that Medicare-enrolled providers and suppliers either form or join an ACO. The ACO must then apply and be accepted into the program. Providers seeking to join an ACO can connect with existing ACOs through regional, state, or national professional associations. A critical eligibility criterion is that ACOs must have a minimum of 5,000 Medicare fee-for-service (FFS) beneficiaries assigned to them in each benchmark year to qualify for the Shared Savings Program.
Exclusivity Rule in Shared Savings Initiatives
Within the Shared Savings Program, exclusivity rules are in place to maintain program integrity. An ACO participant, identified by their Taxpayer Identification Number (TIN) and having a specialty used in beneficiary assignment, must be exclusive to a single Shared Savings Program ACO if they bill Medicare for primary care services. However, individual practitioners with unique National Provider Identifiers (NPIs) can participate in multiple ACOs if they bill under different TINs.
Furthermore, a Medicare-enrolled TIN can only participate in one Medicare shared savings initiative at a time, which includes specific CMS Innovation Center initiatives. For a comprehensive list of CMS Innovation Center models and program overlap details, visit the CMS Innovation Center website.
Interaction with Other CMS Innovation Center Initiatives
CMS offers various Innovation Center initiatives aimed at improving healthcare quality while controlling expenditure growth. These initiatives, though distinct, have key areas of interaction with the Shared Savings Program.
Shared Savings Initiatives Overlap:
ACO participants are restricted from participating in multiple Medicare initiatives that involve shared savings. Examples include:
- ACO Realizing Equity, Access, and Community Health (REACH) Model
- Independence at Home Demonstration with a shared savings arrangement
- Kidney Care Choices (KCC) Model
- Vermont All-Payer ACO Model
CMS may introduce new programs or models with shared savings components in the future.
Non-Shared Savings Initiatives Compatibility:
Shared Savings Program ACOs can participate in CMS Innovation Center initiatives that do not involve shared savings, such as:
- Bundled Payments for Care Improvement (BPCI) Advanced Model
- Comprehensive Primary Care Plus (CPC+)
- Comprehensive Care for Joint Replacement (CJR) Model
- End-Stage Renal Disease (ESRD) Treatment Choices (ETC) Model
- Enhancing Oncology Model (EOM)
- Financial Alignment Initiative for Medicare-Medicaid Enrollees
For a complete list of CMS Innovation Center models and resources for program overlap, refer to the CMS Innovation Center website.
Public Reporting Requirements
The Shared Savings Program mandates that ACOs establish and maintain a public-facing webpage. This webpage must transparently report organizational and programmatic information, including contact details and performance results. CMS provides specific guidelines to ACOs before each public reporting cycle.
Compliance Monitoring and ACO Integrity
Throughout the performance year, ACOs are expected to adhere to all program requirements. Each ACO must appoint a dedicated compliance official and implement a detailed compliance plan, as stipulated in 42 CFR § 425.300.
Beneficiary Assignment Methodology
Beneficiary assignment is a critical aspect of the Shared Savings Program. It is used to calculate the ACO’s financial benchmark, evaluate financial performance annually, and determine the beneficiary sample for quality reporting. Understanding beneficiary assignment is essential for ACOs to effectively manage their performance and outcomes within the program.
Financial Reconciliation Process
ACOs are incentivized to reduce the growth of Medicare Parts A and B expenditures relative to their financial benchmark, while simultaneously meeting rigorous quality performance standards. Financial reconciliation occurs annually after CMS assesses quality performance. Detailed information on beneficiary assignment and benchmark calculation is available in the program’s financial and beneficiary assignment specifications. CMS processes shared savings payments or recoups losses in the fall following each performance year.
Electronic Funds Transfer Authorization
To receive shared savings payments, ACOs must maintain a current Electronic Funds Transfer Authorization Agreement (Form CMS-588). Further details can be found on the Application Guidance & Toolkit webpage.
Telehealth Flexibilities
The Bipartisan Budget Act of 2018 introduced new flexibilities for telehealth services within certain ACOs, effective from January 1, 2020. ACOs in two-sided risk tracks with prospective assignment can bill for specific telehealth services without usual geographic limitations. Beneficiary homes may also qualify as originating sites.
Refer to the Shared Savings Program Telehealth Fact Sheet (PDF) for comprehensive details on expanded telehealth benefits and billing procedures.
Beneficiary Information and Engagement
Beneficiary Notification and Marketing Guidelines
ACOs are required to provide beneficiaries with a Beneficiary Information Notification at or before their first primary care visit within the agreement period. This notification informs beneficiaries about the ACO’s participation in the Shared Savings Program, their option to decline data sharing, and their freedom to choose healthcare providers. ACO participants must display appropriate signage in all facilities and make notifications readily available. Notifications must include the 1-800-MEDICARE helpline for beneficiaries to identify or change their provider for voluntary alignment purposes.
In addition to the initial notification and signage, ACOs must conduct a follow-up communication at the beneficiary’s next primary care visit or within 180 days of the first notification. This follow-up aims to foster a meaningful dialogue about the benefits of ACO care, enhance program transparency, and empower informed decisions about healthcare choices. Acceptable formats for follow-up communication include verbal discussions or written formats, but simply resending the original notification is insufficient. ACOs should maintain records of all follow-up communications, available to CMS upon request.
If an ACO operates a Beneficiary Incentive Program (BIP), beneficiaries must also be informed about its existence.
Empowering Beneficiary Healthcare Decisions through Voluntary Alignment
Voluntary alignment allows Medicare FFS beneficiaries to select a primary clinician, indicating their preferred coordinator for overall care. ACOs must inform beneficiaries about this option and the process to identify or change their voluntarily aligned clinician. Beneficiaries can manage their voluntary alignment preferences on Medicare.gov. Voluntary alignment selections on Medicare.gov take precedence over claims-based assignment methodologies in the Shared Savings Program.
Beneficiary Incentive Program Details
ACOs approved to operate a BIP can offer incentive payments up to $20 to assigned beneficiaries for each qualifying primary care service received, further encouraging engagement and proactive healthcare management.
Quality Performance within the Quality Payment Program for ACOs
Quality Reporting and Measurement under the APM Performance Pathway (APP)
A cornerstone of the Shared Savings Program and the Quality Payment Program is the emphasis on quality. Participating ACOs are mandated to report quality data to CMS annually to be eligible for shared savings and to avoid maximum loss sharing. CMS assesses ACO quality performance using standardized measures.
Since Performance Year 2021, ACOs in the Shared Savings Program are required to report quality measures via the Alternative Payment Model (APM) Performance Pathway (APP). The APP is designed to:
- Alleviate reporting burden for ACOs.
- Introduce new scoring opportunities within the Merit-based Incentive Payment System (MIPS) APMs.
- Promote greater participation in APMs.
The Quality Payment Program offers two distinct tracks for clinicians, and ACOs operate within the APM framework. The APP aligns quality measurement and reporting for ACOs participating in the Shared Savings Program with the broader goals of the Quality Payment Program. This integration ensures that ACOs are actively contributing to national healthcare quality improvement efforts.
Clinicians can check their QPP participation status for each performance year using the QPP Participation Status Lookup Tool. For queries about the lookup tool, contact the QPP Service Center at 1-866-288-8292 (TTY: 1-877-715-6222) or via email at [email protected].
For deeper insights into the interaction between the Quality Payment Program and the Shared Savings Program, the Quality Payment Program Resource Library is an invaluable resource.
Resources for Quality Measurement Performance Program Interactions
For additional information on how the Shared Savings Program interacts with other CMS initiatives, comprehensive resources are available to guide ACOs in navigating these complex relationships and ensuring alignment with quality objectives.
Promoting Interoperability for Enhanced Care Coordination
For performance years starting on or after January 1, 2025, ACO participants who are MIPS eligible clinicians, Qualifying APM Participants (QPs), or Partial Qualifying APM Participants (Partial QPs) must meet specific Promoting Interoperability requirements under MIPS, unless excluded. This involves:
- Reporting MIPS Promoting Interoperability performance category measures and requirements to MIPS at the individual, group, virtual group, or APM Entity level (ACOs report on behalf of their clinicians).
- Achieving a performance category score for MIPS Promoting Interoperability.
These requirements are applicable across all Shared Savings Program tracks, emphasizing the importance of interoperability in enhancing care coordination and quality across the ACO landscape.
Data and Report Sharing for Improved Patient Care
CMS provides ACOs with crucial data on their assigned beneficiary population and financial performance at the beginning of their agreement period and regularly throughout the performance year. To enhance patient care and coordination, Shared Savings Program ACOs can request monthly CCLF files on Medicare FFS beneficiaries who have consented to data sharing. This data sharing initiative supports ACOs in effectively managing and improving the health outcomes of their patient populations.
Financial, Beneficiary Assignment, and Quality Performance Specifications
ACOs are strongly encouraged to consult the program’s detailed financial and beneficiary assignment specifications. These specifications provide in-depth information on beneficiary assignment methodologies and the calculation of historical financial benchmarks used to assess annual financial performance and eligibility for shared savings payments.
Accountable Care Prospective Trend (ACPT) Specifications
The Accountable Care Prospective Trend (ACPT) and Three-Way Blended Benchmark Update Factor Specifications Version 2 (PDF) outlines the ACPT, a key component in the three-way blended update factor for historical benchmarks. This applies to ACOs entering agreement periods from January 1, 2024, onwards, as detailed in the CY 2023 Physician Fee Schedule Final Rule (87 FR 69881).
Current Year Shared Savings, Losses, and Quality Performance Standards
ACOs reconciled for Performance Year 2023 should refer to Version 11 (PDF) for benchmarking and assignment methodologies. For Performance Year 2024, all participating ACOs should consult Version 12 (PDF).
By understanding and adhering to these guidelines, Accountable Care Organizations can effectively navigate the Shared Savings Program and the Quality Payment Program, ultimately improving patient care and achieving success in value-based healthcare.
