The Centers for Medicare & Medicaid Services (CMS) offers various programs designed to enhance healthcare quality and efficiency. Among these, the Medicare Shared Savings Program stands out, encouraging Accountable Care Organizations (ACOs) to deliver coordinated care to Medicare beneficiaries. For those involved in ACOs, particularly concerning the 2019 performance year, understanding the relevant CMS web interfaces and care coding documentation is crucial. This document serves as an expert guide, drawing from official CMS resources to provide a detailed overview of the program, focusing on key aspects relevant to providers and administrators navigating the system.
Program Participation in the Shared Savings Initiative
Understanding Program Participation Information for 2019
For agreement periods initiated on or after July 1, 2019, ACOs commit to a minimum five-year participation in the Shared Savings Program. This commitment period, known as the agreement period, is segmented into performance years, each following similar operational procedures. In 2019, ACOs had the option to participate under either the BASIC track, which included a glide path for eligible ACOs, or the ENHANCED track, offering greater risk and potential for higher rewards. The BASIC track’s glide path allowed ACOs to start under a one-sided risk model and progressively advance through levels of increased risk and reward.
For detailed information on the participation choices available to ACOs, the CMS provides resources like the About the Program webpage. This resource and related 2019 CMS web interface documentation offer critical insights for ACOs aiming to optimize their participation and coding practices. Throughout the agreement period, ACOs are expected to:
- Coordinate patient care, rigorously measure and enhance service quality, and transparently report performance outcomes.
- Prepare diligently for each subsequent performance year by ensuring all contact details are updated within CMS systems, maintaining accurate ACO Participant and Skilled Nursing Facility (SNF) Affiliate Lists, and completing the necessary Annual Certification processes.
- Anticipate and analyze annual financial and quality performance results provided by CMS.
Provider Participation Requirements in 2019
To engage in the Shared Savings Program, Medicare-enrolled providers and suppliers were required to either form or join an ACO. Subsequently, the ACO had to formally apply and be accepted into the Shared Savings Program. For those seeking opportunities to join an ACO, it was recommended to connect with existing ACO participants in their region, state, or through national professional associations. A critical eligibility criterion in 2019 was that ACOs must have had at least 5,000 Medicare fee-for-service (FFS) beneficiaries assigned to them in each benchmark year to qualify for the Shared Savings Program. This requirement ensured that ACOs had a substantial patient base to effectively manage and improve care quality and cost-efficiency.
Exclusivity Rules within the 2019 Program
In 2019, the Shared Savings Program maintained specific exclusivity rules to ensure program integrity and focused participation.
- Within the Shared Savings Program: Any ACO participant, identified by their Taxpayer Identification Number (TIN), with a specialty used in beneficiary assignment (as per 42 CFR 425.402) and billing Medicare for primary care services, was required to be exclusive to a single Shared Savings Program ACO. This rule aimed to prevent overlapping responsibilities and ensure clear accountability. However, individual practitioners, identified by their National Provider Identifiers (NPIs), retained the flexibility to participate in multiple ACOs if they billed under different TINs.
- Among Medicare Shared Savings Initiatives: During any performance year, including 2019, a Medicare-enrolled TIN could only participate in one Medicare shared savings initiative. This restriction extended to certain CMS Innovation Center initiatives, preventing simultaneous participation across similar programs. For a comprehensive list of CMS Innovation Center models and resources concerning program overlaps, the CMS Innovation Center website provided detailed information. Understanding these exclusivity rules was vital for proper enrollment and compliance, especially when navigating the 2019 CMS web interface for program management.
Interaction with Other CMS Innovation Center Initiatives
Numerous Medicare initiatives, including those from the CMS Innovation Center, are designed to foster quality improvements while simultaneously controlling the growth of healthcare expenditures. While distinct, these programs often intersect in critical areas.
- Shared Savings Initiatives: ACO participants were restricted from participating in multiple Medicare initiatives that involved shared savings. These included programs such as:
- ACO Realizing Equity, Access, and Community Health (REACH) Model
- Independence at Home Demonstration with a shared savings arrangement (Patient Protection and Affordable Care Act Sec. 3024)
- Kidney Care Choices (KCC) Model
- Vermont All-Payer ACO Model
It was noted in 2019 that Medicare and the CMS Innovation Center might introduce additional programs with shared savings components in the future, necessitating continuous monitoring for updates via resources like the CMS web interface and program-specific documentation.
- Non-Shared Savings Initiatives: Importantly, Shared Savings Program ACOs could participate in CMS Innovation Center initiatives that did not involve shared savings. These included models like:
- 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 and updated list of CMS Innovation Center models and resources regarding program overlap, the CMS Innovation Center website remained the primary source of information in 2019.
Public Reporting Requirements for ACOs in 2019
The Shared Savings Program mandated that ACOs establish and maintain a dedicated webpage for public reporting. This webpage was to serve as a repository for required organizational and programmatic information, including organizational contact details and performance results. CMS provided specific instructions to ACOs before each public reporting cycle, ensuring transparency and accountability. This public reporting was a key aspect of the 2019 program, enhancing trust and allowing stakeholders to assess ACO performance.
Compliance Monitoring within the 2019 Program Framework
Throughout 2019 and subsequent years, the Shared Savings Program emphasized ACO compliance with program requirements. Each ACO was required to appoint a designated compliance official and develop a comprehensive compliance plan. To participate, ACOs had to adhere to compliance standards as outlined in 42 CFR § 425.300. This regulation specified the elements of an effective compliance plan, ensuring that ACOs operated ethically and in accordance with program guidelines.
Beneficiary Assignment Methodology in 2019
Beneficiary assignment was a fundamental process that underpinned key program operations. It was crucial for:
- Calculating the ACO’s financial benchmark, which served as the baseline for measuring financial performance.
- Assessing the ACO’s financial performance at the conclusion of each performance year, determining shared savings or losses.
- Identifying the ACO’s sample of beneficiaries for quality reporting, ensuring accurate and representative quality metrics.
The methodology used for beneficiary assignment in 2019 and related documentation were typically accessible through the CMS web interface, providing ACOs with the necessary data and tools for program participation.
Financial Reconciliation Process for the 2019 Performance Year
ACOs participating in the Shared Savings Program were incentivized through shared savings when they successfully reduced the growth in Medicare Parts A and B expenditures relative to their financial benchmark, while simultaneously meeting predefined quality performance standards. Financial reconciliation for the performance year occurred annually, following CMS’s assessment of quality performance. Participating ACOs were encouraged to consult the program’s financial and beneficiary assignment specifications for detailed guidance on beneficiary assignment and the calculation of the historical financial benchmark. CMS typically adjudicated shared savings payments or losses in the fall following each performance year. These financial processes, often managed through the CMS web interface, were central to the program’s incentive structure.
Electronic Funds Transfer Authorization Agreement
To facilitate the receipt of shared savings payments, participating ACOs were required to maintain a current Electronic Funds Transfer Authorization Agreement (Form CMS-588). Information and the necessary forms were available through resources like the Application Guidance & Toolkit webpage, ensuring ACOs had the administrative infrastructure to receive payments efficiently.
Telehealth Flexibilities Introduced in 2019 (Effective 2020)
The Bipartisan Budget Act of 2018 brought new flexibilities for physicians and practitioners in certain ACOs regarding telehealth service delivery, effective from January 1, 2020. For ACOs in two-sided risk tracks choosing prospective assignment, billing for specific telehealth services became possible without the usual geographic limitations associated with FFS telehealth coverage. Furthermore, the beneficiary’s home could qualify as an originating site for telehealth services. Detailed information, including the specific telehealth services included in this expanded benefit and billing instructions, was provided in resources such as the Shared Savings Program Telehealth Fact Sheet (PDF). While these flexibilities were legislated in 2018 and impacting 2020, understanding the groundwork laid in 2019 program guidelines was essential for ACOs planning their service delivery models.
Beneficiary Information and ACO Participation
Beneficiary Notification and Marketing Guidelines in 2019
ACOs and their participants had specific responsibilities regarding beneficiary communication. Prior to or at the first primary care visit within the agreement period, each beneficiary was to be provided with a Beneficiary Information Notification. ACO participants were also required to display appropriate signage in all ACO facilities and ensure Beneficiary Information Notifications were readily available upon request in primary care settings. These notifications had to inform beneficiaries about:
- The participation of their providers/suppliers in the Shared Savings Program.
- The beneficiary’s option to decline data sharing with the ACO.
- The beneficiary’s freedom to choose their healthcare providers. Notifications were to include the 1-800-MEDICARE support line for beneficiaries to identify or change their provider for voluntary alignment purposes.
In addition to the initial notification and signage, ACOs were required to conduct a follow-up communication at the beneficiary’s next primary care visit or within 180 days of the initial notification. This follow-up aimed to foster a meaningful dialogue about the benefits of receiving care within an ACO, enhancing program transparency and empowering informed healthcare decisions. Acceptable formats for follow-up communication included verbal or written formats, but simply resending the initial notification was insufficient. The ideal follow-up was a face-to-face discussion, allowing for direct interaction and question-answering. Other acceptable methods included secure patient portals, postal mail, email, or telephone/video visits. ACOs were required to maintain records of all follow-up communications, available to CMS upon request, demonstrating adherence to patient communication protocols in the 2019 program year. If an ACO operated a Beneficiary Incentive Program (BIP), beneficiaries also needed to be informed about its existence.
Empowering Patient Choice in Healthcare Decisions
Voluntary alignment was a process that allowed Medicare FFS beneficiaries to actively select or “voluntarily align” with a primary clinician. ACOs were responsible for informing beneficiaries about this option and the process for identifying or changing their chosen clinician. Beneficiaries could use Medicare.gov to select their primary clinician—the provider they believed was most responsible for coordinating their overall care. The Shared Savings Program prioritized these voluntary selections made on Medicare.gov over claims-based assignment methodologies. This emphasis on patient choice was a key element of the 2019 program’s beneficiary-centric approach.
Beneficiary Incentive Program Guidance
ACOs approved to implement a Beneficiary Incentive Program (BIP) could provide incentive payments, up to $20 per qualifying primary care service, to each assigned beneficiary. This was designed to encourage beneficiary engagement and promote proactive healthcare management within the ACO framework.
Quality Reporting and Measurement in the 2019 Program
Quality Reporting and Measurement Protocols
Participation in the Shared Savings Program required ACOs to report quality data to CMS annually, subsequent to each performance year. This reporting was crucial for eligibility to share in any earned savings and to avoid maximum loss sharing. CMS evaluated each ACO’s quality performance using standardized measurement methods. Starting in performance year 2021, ACOs were mandated to report quality measures via the Alternative Payment Model (APM) Performance Pathway (APP) for Shared Savings Program quality assessment. However, the quality framework established and documented in 2019 set the stage for these subsequent changes. The APP was designed to:
- Reduce the reporting burden on ACOs.
- Create new scoring opportunities for participants within Merit-based Incentive Payment System (MIPS) APMs.
- Encourage broader participation in APMs by streamlining quality reporting processes.
Resources providing details on the Shared Savings Program quality measurement and the APP were made available by CMS to guide ACOs through the reporting requirements. Specifications and benchmarks applicable to the APP for PY 2023 and PY 2024 were also documented and accessible through CMS resources, building upon the foundational quality measures of 2019.
Quality Payment Program Interaction
The Quality Payment Program (QPP) aimed to enhance Medicare by focusing provider attention on care quality, ultimately striving to improve patient health outcomes. The QPP offered clinicians two participation tracks:
Clinicians could verify their QPP participation status for any performance year using the QPP Participation Status Lookup Tool by entering their 10-digit National Provider Identifier number. For queries related to the QPP Participation Status Lookup Tool, the QPP Service Center was available at 1-866-288-8292, (TTY) 1-877-715-6222, or via email at [email protected]. Further information on the interaction between the Quality Payment Program and the Shared Savings Program was available on the Quality Payment Program Resource Library webpage. Understanding these interactions was crucial for ACOs navigating both programs in 2019.
Promoting Interoperability in Healthcare
For performance years starting on or after January 1, 2025, specific Promoting Interoperability requirements were set for ACO participants, providers/suppliers, and ACO professionals who were MIPS eligible clinicians, Qualifying APM Participants (QPs), or Partial Qualifying APM Participants (Partial QPs). Unless excluded, these participants were required to:
- Report MIPS Promoting Interoperability performance category measures and requirements to MIPS at the individual, group, virtual group, or APM Entity level. This meant ACOs often reported on behalf of their clinicians.
- Achieve a performance category score for MIPS Promoting Interoperability at the individual, group, virtual group, or APM Entity level.
These requirements applied universally, irrespective of the Shared Savings Program track in which the ACO participant or professional was involved. While these requirements were for future years, the emphasis on interoperability was already a topic of discussion and planning within ACOs in 2019, setting the stage for enhanced data exchange and patient care coordination.
Data and Report Sharing Mechanisms
CMS provided ACOs with essential data on their assigned beneficiary population and financial performance at the onset of their agreement period and routinely throughout each performance year. To improve patient treatment and care coordination, Shared Savings Program ACOs could request monthly CCLF (CMS Chronic Condition Data Warehouse Claims and Claims-Based Quality Measures Feedback) files. These files contained data on Medicare FFS beneficiaries who had not opted out of data sharing, facilitating data-driven improvements in care delivery.
Financial, Beneficiary Assignment, and Quality Performance Standards
Participating ACOs were consistently directed to refer to the program’s financial and beneficiary assignment specifications. These specifications provided detailed insights into how the Shared Savings Program assigned beneficiaries to each ACO and how historical financial benchmarks were calculated. These benchmarks were crucial for assessing annual financial performance and determining eligibility for shared savings payments. Understanding these specifications, often detailed in documents accessible through the CMS web interface, was paramount for ACO financial planning and performance management in 2019.
Accountable Care Prospective Trend (ACPT) Specifications
The Accountable Care Prospective Trend (ACPT) and Three-Way Blended Benchmark Update Factor Specifications Version 2 (PDF) described the ACPT. This was a component of the three-way blended update factor applied to the historical benchmark for ACOs entering agreement periods from January 1, 2024, onwards. This was outlined in the CY 2023 Physician Fee Schedule Final Rule (87 FR 69881). While these specifications were forward-looking from 2019, understanding the evolution of benchmark calculations was important for long-term ACO strategic planning.
Current Year Shared Savings, Losses, and Performance Specifications
ACOs reconciled for PY 2023 were directed to refer to the benchmarking methodology and assignment sections in Version 11 (PDF). For all ACOs participating in PY 2024, reference was made to Version 12 (PDF). These documents, updated annually, provided the most current guidelines for financial reconciliation, beneficiary assignment, and quality performance standards, essential for ACOs to navigate the program effectively in 2019 and beyond.
This comprehensive guide aims to provide clarity and direction for stakeholders involved in Accountable Care Organizations, particularly concerning the 2019 Medicare Shared Savings Program. By understanding the program’s intricacies, including the use of CMS web interfaces and relevant care coding documentation, ACOs can better navigate the landscape of value-based healthcare and improve patient outcomes.
