Program Statutes & Regulations
Program Statutes & Regulations
Find statutes and regulatory documents describing the establishment of and further modifications to the Medicare Shared Savings Program (Shared Savings Program) through stand-alone rules and sections within the annual Physician Fee Schedule (PFS) rules. For the Shared Savings Program regulations, refer to the eCFR. For details on changes to the regulations, please refer to the Federal Register publications listed below.
Statutory Basis
Congress enacted the Patient Protection and Affordable Care Act (Pub.L. 111-148) on March 23, 2010. Section 3022 of the Affordable Care Act amended Section 1899 of the Social Security Act (the Act) and established the Shared Savings Program. To learn more, refer to the Affordable Care Act and Social Security Act.
More recently, the requirements for assignment under the program were amended by the 21st Century Cures Act (December 2016). The 21st Century Cures Act amended the Act to require the Secretary of Health and Human Services to assign beneficiaries to Accountable Care Organizations (ACOs) participating in the Shared Savings Program based not only on their utilization of primary care services furnished by physicians, but also on their utilization of services furnished by Rural Health Centers (RHCs) and Federally Qualified Health Centers (FQHCs), effective for performance years beginning on or after January 1, 2019. In addition, the Bipartisan Budget Act of 2018 (BBA of 2018) established additional tools and flexibilities for ACOs specifically in the areas of new beneficiary incentives, telehealth services, and choice of beneficiary assignment methodology.
Shared Savings Program Rule Making
2024, 2023, 2022, 2021, 2020, 2019, 2018, 2017, 2016, 2015, 2014, 2011
2024
Physician Fee Schedule (PFS) Final Rule
November 1, 2024
On November 1, 2024, CMS issued a final rule entitled Medicare and Medicaid Programs; CY 2025 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Prescription Drug Inflation Rebate Program; and Medicare Overpayments, which includes finalized changes to the Shared Savings Program to further advance Medicare’s value-based care strategy of growth, alignment, and equity.
To learn more, refer to:
- Press Release: HHS Finalizes Physician Payment Rule Strengthening Person-Centered Care and Health Quality Measures
- Shared Savings Program Fact Sheet: Calendar Year (CY) 2025 Medicare Physician Fee Schedule (PFS) Final Rule (CMS-1807-F) - Medicare Shared Savings Program Provisions
- Final Rule: Calendar Year (CY) 2025 PFS Final Rule
- Fact Sheet: CY 2025 Medicare Physician Fee Schedule Final Rule
- Quality Payment Program (QPP): QPP 2025 Final Rule Resources
Significant, Anomalous, and Highly Suspect (SAHS) Billing Activity Final Rule
https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3057/2025-QPP-Policies-Final-Rule-Fact-Sheet.pdf
September 24, 2024
On September 24, 2024, CMS issued a final rule entitled Medicare Program: Mitigating the Impact of Significant, Anomalous, and Highly Suspect Billing Activity on Medicare Shared Savings Program Financial Calculations in Calendar Year 2023, which mitigates the impact of SAHS billing activity for two codes for intermittent urinary catheters on Medicare Durable Medical Equipment, Prosthetics, Orthotics & Supplies claims, on performance year (PY) 2023 financial performance of Shared Savings Program Accountable Care Organizations (ACOs); benchmarks for ACOs starting agreement periods in 2024, 2025, and 2026; and factors used in the application cycle for ACOs applying to enter a new agreement period beginning on January 1, 2025, and continuing their participation in the program for PY 2025.
To learn more, refer to:
- Shared Savings Program Fact Sheet: Final Rule on Mitigating the Impact of Significant, Anomalous, and Highly Suspect Billing Activity on Medicare Shared Savings Program Financial Calculations in Calendar Year 2023 (CMS-1799-F)
- Final Rule: Shared Savings Program SAHS billing activity
Physician Fee Schedule Proposed Rule
July 10, 2024
On July 10, 2024, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule entitled Medicare and Medicaid Programs; CY 2025 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Prescription Drug Inflation Rebate Program; and Medicare Overpayments, which includes proposed changes to the Shared Savings Program to further advance Medicare’s value-based care strategy of growth, alignment, and equity.
To learn more, refer to:
- Press Release: HHS Proposes Physician Payment Rule to Drive Whole-Person Care and Improve Health Quality for All Individuals with Medicare
- Shared Savings Program Fact Sheet: CY 2025 PFS Proposed Rule Medicare Shared Savings Program Proposals
- Quality Payment Program Fact Sheet and Policy Comparison Table: CY 2025 PFS Notice of Proposed Rulemaking: Quality Payment Program (QPP) Fact Sheet and Policy Comparison Table
- PFS Fact Sheet: CY 2025 PFS Proposed Rule
- Proposed Rule: CY 2025 PFS Proposed Rule
Significant, Anomalous, and Highly Suspect (SAHS) Billing Activity Proposed Rule
June 28, 2024
On June 28, 2024, CMS issued a proposed rule entitled Medicare Program: Mitigating the Impact of Significant, Anomalous, and Highly Suspect Billing Activity on Medicare Shared Savings Program Financial Calculations in Calendar Year 2023, which addresses policies for assessing performance year (PY) 2023 financial performance of Medicare Shared Savings Program Accountable Care Organizations (ACOs); establishing benchmarks for ACOs starting agreement periods in 2024, 2025, and 2026; and calculating factors used in the application cycle for ACOs applying to enter a new agreement period beginning on January 1, 2025, and the change request cycle for ACOs continuing their participation in the program for PY 2025, as a result of SAHS billing activity for selected intermittent urinary catheters on Medicare Durable Medical Equipment, Prosthetics, Orthotics & Supplies claims.
To learn more, refer to:
- Shared Savings Program Fact Sheet: Proposed Rule on Mitigating the Impact of Significant, Anomalous, and Highly Suspect Billing Activity on Medicare Shared Savings Program Financial Calculations in Calendar Year 2023 (CMS-1799-P)
- Proposed Rule: Shared Savings Program SAHS billing activity
HHS Information Blocking Disincentives Final Rule
June 24, 2024
On June 24, 2024, the U.S. Department of Health and Human Services (HHS) released a final rule that establishes disincentives for health care providers found by the HHS Office of Inspector General (OIG) to have committed information blocking—a practice of interfering with the access, exchange, or use of electronic health information. The final rule implements the HHS secretary’s authority under Section 4004 of the 21st Century Cures Act (Cures Act). The final rule complements OIG’s rule that established information blocking penalties for the other actors identified by Congress (health information technology (IT) developers of certified health IT or other entities offering certified health IT, health information exchanges, and health information networks).
- In this final rule, HHS establishes that under the Shared Savings Program, a health care provider that is an ACO, ACO participant, or ACO provider or supplier who has committed information blocking may be ineligible to participate in the program for a period of at least one year. CMS will consider relevant facts and circumstances (e.g., time since the conduct, diligence in correcting the conduct, other disincentives applied) prior to applying a disincentive under the Shared Savings Program.
To learn more, refer to:
- HHS Press Release: HHS Finalizes Rule Establishing Disincentives for Health Care Providers That Have Committed Information Blocking
- ONC Webpage on Information Blocking
2023
Physician Fee Schedule Final Rule
November 2, 2023
On November 2, 2023, the CMS issued a final rule entitled Medicare and Medicaid Programs; CY 2024 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; etc., which includes changes to the Shared Savings Program to advance CMS’ overall value-based care strategy of growth, alignment, and equity.
To learn more, refer to:
- Press Release: CMS Finalizes Physician Payment Rule that Advances Health Equity
- Shared Savings Program Fact Sheet: Calendar Year (CY) 2024 Medicare Physician Fee Schedule Final Rule — Medicare Shared Savings Program Fact Sheet
- 2024 QPP Final Rule Fact Sheet and Policy Comparison Table (PDF)
- Physician Fee Schedule (PFS) Fact Sheet: Calendar Year (CY) 2024 Medicare Physician Fee Schedule Final Rule
- Final Rule: CY 2024 PFS Final Rule
HHS Information Blocking Disincentives Proposed Rule
October 30, 2023
On October 30, 2023, the HHS released a proposed rule for public comment that would establish disincentives for health care providers found by the HHS Office of Inspector General (OIG) to have committed information blocking—a practice of interfering with the access, exchange, or use of electronic health information. The proposed rule implements the HHS secretary’s authority under Section 4004 of the 21st Century Cures Act (Cures Act). The proposed rule complements OIG’s rule that established information blocking penalties for the other actors identified by Congress (health information technology (IT) developers of certified health IT or other entities offering certified health IT, health information exchanges, and health information networks).
In this proposed rule, HHS proposes to establish the following disincentives for providers that have been determined by OIG to have committed information blocking: Under the Medicare Shared Savings Program, a health care provider would be deemed ineligible to participate in the program for a period of at least one year. This may result in a health care provider being removed from an ACO or prevented from joining an ACO. Restricting the ability of health care providers to participate in the Shared Savings Program for at least 1 year would result in these health care providers potentially not receiving revenue that they might otherwise have earned if they had participated in the Shared Savings Program.
CMS encourages interested parties to review and submit comments on the proposed rule. Public comments on the proposed rule are due on January 2, 2024. Official comments must be submitted in one of the following ways: electronically through the Regulations.gov website, regular mail, or express or overnight mail. In commenting, please refer to file code RIN 0955-AA05.
To learn more, refer to:
- Information Blocking Disincentives Proposed Rule
- HHS press release
- Office of the National Coordinator for Health IT (ONC)/CMS blog
- ONC webpage on information blocking
Physician Fee Schedule Proposed Rule
July 13, 2023
On July 13, 2023, the CMS issued a proposed rule entitled Medicare and Medicaid Programs; CY 2024 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Continued Implementation of Requirements for Manufacturers of Certain Single-dose Container or Single-use Package Drugs to Provide Refunds with Respect to Discarded Amounts; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment Policies; and Basic Health Program, which includes proposed changes to the Shared Savings Program to advance CMS’ overall value-based care strategy of growth, alignment, and equity.
To learn more, refer to:
- Press Release: CMS Physician Payment Rule Advances Health Equity
- Shared Savings Program Fact Sheet: Calendar Year (CY) 2024 Medicare Physician Fee Schedule Proposed Rule — Medicare Shared Savings Program Proposals
- 2024 QPP Proposed Rule Fact Sheet and Policy Comparison Table (PDF)
- Physician Fee Schedule (PFS) Fact Sheet: Calendar Year (CY) 2024 Medicare Physician Fee Schedule Proposed Rule
- Proposed Rule: CY 2024 PFS proposed rule
2022
Physician Fee Schedule Final Rule
November 1, 2022
On November 1, 2022, CMS issued the PFS final rule entitled Medicare and Medicaid Programs; CY 2023 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements, Etc., which includes changes to the Shared Savings Program to advance CMS’ overall value-based care strategy of growth, alignment, and equity. The Calendar Year (CY) 2023 PFS Final Rule makes regulatory changes to Shared Savings Program policies, including to: provide advance shared savings payments in the form of advance investment payments (AIPs) to certain new, low revenue ACOs that can be used to support their participation in the Shared Savings Program; provide greater flexibility in the progression to performance-based risk; establish a health equity adjustment to an ACO’s Merit-based Incentive Payment System (MIPS) quality performance category score used to determine shared savings and losses to recognize high quality performance by ACOs serving a higher proportion of underserved populations; incorporate a sliding scale reflecting an ACO’s quality performance for use in determining shared savings for ACOs, and revise the approach for determining shared losses for ENHANCED track ACOs; modify the benchmarking methodology to strengthen financial incentives for long term participation by reducing the impact of ACOs’ performance and market penetration on their benchmarks, and to support the business case for ACOs serving high risk and high dually eligible populations to participate, as well as mitigate bias in regional expenditure calculations for ACOs electing prospective assignment; expand opportunities for certain low revenue ACOs participating in the BASIC track to share in savings; make changes to policies within other programmatic areas, including the program’s beneficiary assignment methodology, requirements related to marketing material review and beneficiary notifications, the Skilled Nursing Facility (SNF) 3-day rule waiver application, and data sharing requirements.
To learn more, refer to:
- Press Release: HHS Finalizes Physician Payment Rule Strengthening Access to Behavioral Health Services and Whole-Person Care
- Shared Savings Program Fact Sheet: Calendar Year (CY) 2023 Medicare Physician Fee Schedule Final Rule – Medicare Shared Savings Program (PDF)
- PFS Fact Sheet: Calendar Year (CY) 2023 Medicare Physician Fee Schedule Final Rule
- Quality Payment Program (QPP) Fact Sheet: 2023 QPP Final Rule Resources
- Final Rule: CY 2023 PFS
July 7, 2022
On July 7, 2022, CMS issued a proposed rule entitled Medicare and Medicaid Programs: Calendar Year 2023 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies, Medicare Shared Savings Program Requirements, etc., which includes proposed changes to the Shared Savings Program to advance CMS’ overall value-based care strategy of growth, alignment, and equity.
To learn more, refer to:
- Press Release: CMS Proposes Physician Payment Rule to Expand Access to High-Quality Care
- Fact Sheet: Calendar Year (CY) 2023 Medicare Physician Fee Schedule Proposed Rule - Medicare Shared Savings Program Proposals
- PFS Fact Sheet: Calendar Year (CY) 2023 Medicare Physician Fee Schedule Proposed Rule
- QPP Fact Sheet: 2023 Quality Payment Program Proposed Rule Resources
- Proposed Rule: CY 2023 PFS proposed rule
- County-level Aggregate Expenditure and Risk Score Data on Assignable Beneficiaries Public Use File (ZIP)
2022
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Physician Fee Schedule Final Rule
November 1, 2022
On November 1, 2022, CMS issued the PFS final rule entitled Medicare and Medicaid Programs; CY 2023 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements, Etc., which includes changes to the Shared Savings Program to advance CMS’ overall value-based care strategy of growth, alignment, and equity. The Calendar Year (CY) 2023 PFS Final Rule makes regulatory changes to Shared Savings Program policies, including to: provide advance shared savings payments in the form of advance investment payments (AIPs) to certain new, low revenue ACOs that can be used to support their participation in the Shared Savings Program; provide greater flexibility in the progression to performance-based risk; establish a health equity adjustment to an ACO’s Merit-based Incentive Payment System (MIPS) quality performance category score used to determine shared savings and losses to recognize high quality performance by ACOs serving a higher proportion of underserved populations; incorporate a sliding scale reflecting an ACO’s quality performance for use in determining shared savings for ACOs, and revise the approach for determining shared losses for ENHANCED track ACOs; modify the benchmarking methodology to strengthen financial incentives for long term participation by reducing the impact of ACOs’ performance and market penetration on their benchmarks, and to support the business case for ACOs serving high risk and high dually eligible populations to participate, as well as mitigate bias in regional expenditure calculations for ACOs electing prospective assignment; expand opportunities for certain low revenue ACOs participating in the BASIC track to share in savings; make changes to policies within other programmatic areas, including the program’s beneficiary assignment methodology, requirements related to marketing material review and beneficiary notifications, the Skilled Nursing Facility (SNF) 3-day rule waiver application, and data sharing requirements.
To learn more, refer to:
- Press Release: HHS Finalizes Physician Payment Rule Strengthening Access to Behavioral Health Services and Whole-Person Care
- Shared Savings Program Fact Sheet: Calendar Year (CY) 2023 Medicare Physician Fee Schedule Final Rule – Medicare Shared Savings Program (PDF)
- PFS Fact Sheet: Calendar Year (CY) 2023 Medicare Physician Fee Schedule Final Rule
- Quality Payment Program (QPP) Fact Sheet: 2023 QPP Final Rule Resources
- Final Rule: CY 2023 PFS
2021
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Physician Fee Schedule Final Rule
November 2, 2021
On November 2, 2021, CMS issued a final rule entitled CY 2022 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Provider Enrollment Regulation Updates; and Provider and Supplier Prepayment and Post-payment Medical Review Requirements (herein CY 2022 PFS Final Rule). The CY 2022 PFS Final Rule includes regulatory changes to the Medicare Shared Savings Program including a longer transition for ACOs to report electronic clinical quality measures/Merit-based Incentive Payment System clinical quality measures (eCQM/MIPS CQM) by extending the CMS Web Interface collection type through PY 2024 and maintaining the quality performance standard ACOs must meet to be eligible to share in savings for PY 2023; updates to the definition of primary care services used in beneficiary assignment; revisions to the methodology for calculating repayment mechanism amounts for risk-based ACOs that reduces the amount by 50 percent and clarifies how we identify the number of assigned beneficiaries used in the repayment mechanism calculations; and reduces burden and streamlines the application and beneficiary notification processes. These changes to the Shared Savings Program are described in further detail via the links below.
To learn more, refer to:
Press Release: CMS Physician Payment Rule Promotes Greater Access to Telehealth Services, Diabetes Prevention Programs Final Rule: CY 2022 PFS Fact Sheet: Calendar Year (CY) 2022 Medicare Physician Fee Schedule Final Rule QPP: QPP 2022 Final Rule Resources (ZIP)
Fiscal Year (FY) 2022 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) Proposed Rule Proposes to Allow ACOs to “Freeze” Participation on BASIC Track Glide Path for PY 2022
April 27, 2021
On April 27, 2021, CMS issued a proposed rule, entitled “Fiscal Year (FY) 2022 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) Rates Proposed Rule (CMS-1752-P)”, that includes a proposal to allow eligible ACOs participating in the BASIC track’s glide path option to elect to forgo automatic advancement along the glide path’s increasing levels of risk and potential reward for PY 2022.
To learn more, refer to:
CMS-1752-P Fact Sheet: Fiscal Year (FY) 2022 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) Rates Proposed Rule (CMS-1752-P) Press Release: CMS Proposes to Enhance the Medical Workforce in Rural and Underserved Communities to Support COVID-19 Recovery and Beyond Proposed Rule: FY 2022 Medicare Hospital IPPS and LTCH Rates Proposed Rule (CMS-1752-P) QPP Fact Sheet: CY 2022 Physician Fee Schedule Notice of Proposed Rule Making: Quality Payment Program (QPP) Proposals Overview PFS Fact Sheet: CY 2022 Medicare Physician Fee Schedule Proposed Rule Press Release: CMS Proposes Physician Payment Rule to Improve Health Equity, Patient Access Proposed Rule: CY 2022 PFS
Physician Fee Schedule Proposed Rule
July 13, 2021
On July 13, 2021, CMS issued a proposed rule entitled Medicare Program: CY 2022 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies; "Medicare Shared Savings Program Requirements; Provider Enrollment Regulation Updates; Provider and Supplier Prepayment and Post-payment Medical Review Requirements" (herein CY 2022 PFS proposed rule).
The CY 2022 PFS proposed rule includes proposals for the Shared Savings Program and QPP.
Proposals to amend Shared Savings Program policies are discussed, primarily, in section III.J.
To learn more, refer to:
Fiscal Year (FY) 2022 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) Rates Final Rule
August 2, 2021
On August 2, 2021, CMS issued the final rule for Fiscal Year (FY) 2022 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) Prospective Payment System (PPS) that includes policies to allow eligible ACOs participating in the BASIC track’s glide path the option to elect to forgo automatic advancement along the glide path’s increasing levels of risk and potential reward for PY 2022.
To learn more, refer to:
CMS-1752-F Fact Sheet: Fiscal Year (FY) 2022 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) Rates Final Rule (CMS-1752-F) Press Release: CMS Final Rule Improves Health Equity, Access to Treatment, Hospital Readiness, and COVID-19 Vaccination Data Reporting of Hospital Workers Final Rule: Fiscal Year (FY) 2022 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) Prospective Payment System (PPS)
2020
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Physician Fee Schedule Final Rule
December 1, 2020
On December 1, 2020, CMS issued the Medicare Physician Fee Schedule final rule that includes regulatory changes to the Shared Savings Program; including, changes to the Shared Savings Program quality performance standard and quality reporting requirements for performance years beginning on January 1, 2021, to align with Meaningful Measures, reduce reporting burden and focus on patient outcomes. CMS finalized the proposal to waive the requirement for ACOs to field a Consumer Assessment of Healthcare Providers and Systems (CAHPS®) for ACOs patient experience of care surveys and ACOs will receive automatic full credit for the patient experience of care measures. The final rule also includes other changes to the Shared Savings Program that are described in further detail via the links below.
To learn more, refer to:
- PFS Fact Sheet: Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2021 QPP 2021 Final Rule Resources (ZIP)
- QPP: QPP 2021 Final Rule Resources (ZIP)
- Final Rule: CY 2021 PFS
- Press Release: Trump Administration Finalizes Permanent Expansion of Medicare Telehealth Services and Improved Payment for Time Doctors Spend with Patients
Physician Fee Schedule Proposed Rule
August 4, 2020
To learn more, refer to:
- PFS Fact Sheet: Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2021
- QPP: QPP Fact Sheet: 2021 Quality Payment Program Proposed Rule Overview Fact Sheet
- Press Release: Trump Administration Proposes to Expand Telehealth Benefits Permanently for Medicare Beneficiaries Beyond the COVID-19 Public Health Emergency and Advances Access to Care in Rural Areas
- Proposed Rule: CY 2021 Physician Fee Schedule Notice of Proposed Rule Making
Interim Final Rule with Comment Released Announcing Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency
April 30, 2020
On April 30, 2020, CMS made changes to the Shared Savings Program to give the 517 ACOs serving more than 11 million beneficiaries greater financial stability and predictability during the coronavirus disease 2019 (COVID-19) pandemic.
Because the impact of the pandemic varies across the country, CMS is making adjustments to the financial methodology to account for COVID-19 costs so that ACOs will be treated equitably regardless of the extent to which their patient populations are affected by the pandemic. CMS is also forgoing the annual application cycle for 2021 and giving ACOs whose participation is set to end this year the option to extend for another year. ACOs that are required to increase their financial risk over the course of their current agreement period in the program will have the option to maintain their current risk level for next year, instead of being advanced automatically to the next risk level.
ACOs and their participating health care providers are using telehealth visits to continue to coordinate and deliver high quality care to their assigned beneficiaries. Consequently, for PY 2020 and any subsequent performance year that starts during the public health emergency, CMS is including additional codes within the definition of primary care services used in determining beneficiary assignment under the Shared Savings Program so CMS can appropriately assign beneficiaries to ACOs based on remotely provided primary care services.
For more information, refer to the following:
- PFS Fact Sheet: Medicare Shared Savings Program: CMS Flexibilities to Fight COVID-19 (PDF)
- Press Release: Trump Administration Issues Second Round of Sweeping Changes to Support U.S. Healthcare System During COVID-19 Pandemic
- FAQ: COVID-19 FAQs on Medicare Fee-for-Service Billing (PDF) (Refer to Section U: Medicare Shared Savings Program - Accountable Care Organizations (ACO)) IFC, effective May 8, 2020
Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency
March 30, 2020
On March 30, 2020, CMS released the Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 public health emergency (PHE) interim final rule with comment period. This Interim final rule with comment period (IFC) gives individuals and entities that provide services to Medicare beneficiaries needed flexibilities to respond effectively to the public health threats posed by the spread of the COVID-19. In the IFC, CMS finalized a modification to the extreme and uncontrollable circumstances policy under the Shared Savings Program (See pages 129-135 of the IFC).
To learn more, refer to the following
- Fact Sheet: Additional Background: Sweeping Regulatory Changes to Help U.S. Healthcare System Address COVID-19 Patient Surge.
- Press Release: Trump Administration Makes Sweeping Regulatory Changes to Help U.S. Healthcare System Address COVID-19 Patient Surge
- FAQ: COVID-19 FAQs on Medicare Fee-for-Service Billing (PDF) (Refer to Section U: Medicare Shared Savings Program - Accountable Care Organizations (ACO)) IFC, effective March 31, 2020
2019
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Physician Fee Schedule Final Rule
November 1, 2019
The Medicare PFS final rule published in November 2019 includes updates to payment policies and payment rates for services furnished under the PFS on or after January 1, 2020. The rule also includes finalized policies for the Shared Savings Program and Year 4 (2020) of the QPP. CMS finalized the following refinements to the Shared Savings Program measure set:
Reverting ACO-43: Ambulatory Sensitive Condition Acute Composite Prevention Quality Indicator (PQI) #91 (version with additional risk adjustment) measure to pay-for-reporting for PY 2020 and PY 2021 due to a substantive change made by the measure owner. Maintaining ACO-17: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention as pay-for-reporting for PY 2019 as the QPP is finalizing a substantive change to the numerator guidance for the measure. Finalizing the technical change to correct a cross-reference within a provision of the Shared Savings Program’s regulations on the SNF 3-Day Rule Waiver, to conform with amendments to § 425.612 that were adopted in the December 2018 Final Rule.
For more information, refer to the following:
- Fact Sheet: Finalized Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for CY 2020
- Final Rule: CY 2020 PFS
Proposed Rule
July 29, 2019
For more information, refer to the following:
2018
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Shared Savings Program Final Rule
December 31, 2018
On December 31, 2018, CMS published a final rule that sets a new direction for the Shared Savings Program. Referred to as “Pathways to Success,” the final rule streamlines and redesigns the participation options available under the Shared Savings Program to encourage ACOs to transition to performance-based risk more gradually and incrementally to increase savings for the Trust Funds. The policies also include changes to address the additional tools and flexibilities for ACOs established by the BBA of 2018, specifically in the areas of new beneficiary incentives, telehealth services, and choice of beneficiary assignment methodology.
For more information, refer to the following:
- Final Rule: Federal Register December 2018 Final Rule
Physician Fee Schedule Final Rule
November 23, 2018
The PFS final rule published in November 2018 addresses a subset of changes to the Shared Savings Program for ACOs proposed in the August 2018 proposed rule “Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations Pathways to Success” and addresses various other revisions designed to update program policies under the Shared Savings Program. In order to ensure continuity of participation, finalize time-sensitive program policy changes for currently participating ACOs, and streamline the ACO core quality measure set to reduce burden and encourage better outcomes, CMS is finalizing the following policies:
- A voluntary 6-month extension for existing ACOs whose participation agreements expire on December 31, 2018, and the methodology for determining financial and quality performance for this 6-month performance year from January 1, 2019, through June 30, 2019.
- Reducing the Shared Savings Program core quality measure set by eight measures; and promoting interoperability among ACO providers and suppliers by adding a new Certified Electronic Heath Record (EHR) Technology (CEHRT) threshold criterion to determine ACOs’ eligibility for program participation and retiring the current Shared Savings Program quality measure on the percentage of eligible clinicians using CEHRT.
- Allowing beneficiaries who voluntarily align to a Nurse Practitioner, Physician Assistant, Certified Nurse Specialist, or a physician with a specialty not used in assignment to be prospectively assigned to an ACO if the clinician they align with is participating in an ACO, as provided for in the Bipartisan Budget Act of 2018.
- Providing relief for ACOs and their clinicians impacted by extreme and uncontrollable circumstances in 2018 and subsequent years.
- Revising the definition of primary care services used in beneficiary assignment.
To learn more, refer to CY 2019 PFS Final Rule.
Proposed Rule
August 9, 2018
To learn more, refer to Federal Register August 2018 Notice of Proposed Rule Making.
Proposed Rule
July 12, 2018
To learn more, refer to CY 2019 PFS.
2017
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Shared Savings Program Interim Final Rule for Extreme and Uncontrollable Circumstances
December 26, 2017
CMS published an IFC that established policies for assessing the quality and financial performance of Shared Savings Program ACOs affected by extreme and uncontrollable circumstances, such as Hurricanes Harvey, Irma, Maria, and the California wildfires, during PY 2017. The IFC includes the following:
CMS will use the same determination of geographic areas impacted by an extreme and uncontrollable circumstance as the QPP. ACOs with 20 percent or more of their assigned beneficiaries who reside in impacted counties, or an ACO legal entity located in impacted counties, will receive the higher of their ACO reported quality score or the mean Shared Savings Program ACO quality score. Performance-based risk ACOs will have any owed losses adjusted for the percent of the ACO’s assigned beneficiaries residing in impacted counties and the length of the emergency declaration.
To learn more, refer to Federal Register December 2017 IFC.
Physician Fee Schedule Final Rule
November 15, 2017
The PFS final rule published in November 2017 includes the following:
- Modifications to the Shared Savings Program beneficiary assignment methodology for Performance Year 2019 and subsequent years.
- Revisions to the ACO core quality measure set.
- SNF 3-Day Rule Waiver Application requirement that ACOs report their financial relationships and modifications to the Shared Savings Program Initial Application.
- Addressing compliance with ACO participant taxpayer identification number (TIN) exclusivity requirement.
- Treatment of individually beneficiary-identifiable payments made under a demonstration, pilot, or time limited program.
To learn more, refer to Details for CY 2018 PFS Final Rule.
Proposed Rule
July 21, 2017
To learn more, refer to Details for Proposed CY 2018 Revisions to Payment Policies Under PFS.
2016
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Physician Fee Schedule Final Rule
November 15, 2016
The PFS final rule published in November 2016 included the following:
- Revisions permitting eligible professionals in ACOs to report quality apart from the ACO including during the 2016 Physician Quality Reporting System (PQRS) special reporting period for eligible professionals.
- Modifications to the assignment algorithm to align beneficiaries to an ACO when a beneficiary has designated an ACO professional as responsible for their overall care.
To learn more, refer to Details for CY 2017 Revisions to Payment Policies Under PFS.
Proposed Rule
July 15, 2016
To learn more, refer to Details for Proposed CY 2017 Revisions to Payment Policies Under PFS.
Shared Savings Program Final Rule
June 10, 2016
The new final rule published in June 2016 included the following:
- Revisions to the approach for resetting (or rebasing) an ACO's benchmark for a second or subsequent agreement period beginning on or after January 1, 2017, to take into account regional fee-for-service (FFS) expenditures.
- Revisions to the methodology for national FFS calculations to use assignable Medicare FFS beneficiaries (a subset of the broader FFS population) instead of all FFS beneficiaries.
- Addition of an option for ACOs participating under Track 1 to apply to renew for a second agreement period under a two-sided model (Track 2 or Track 3). If the ACO’s renewal request is approved, the ACO may request that its initial participation agreement under Track 1 be extended for an additional year (that is, the ACO would enter a fourth performance year under Track 1).
To learn more, refer to:
Proposed Rule
February 3, 2016
To learn more, refer to:
2015
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Physician Fee Schedule Final Rule
November 16, 2015
The PFS final rule published in November 2015 included the following:
- Clarifying how PQRS-eligible professionals participating within an ACO meet their PQRS reporting requirements when their ACO satisfactorily reports quality.
- Amending the definition of primary care services to include claims submitted by Electing Teaching Amendment (ETA) hospitals and exclude claims submitted by SNFs when the claim contains the place-of-service 31 modifier.
To learn more, refer to Details for CY 2016 Revisions to Payment Policies Under PFS.
Proposed Rule
July 15, 2015
To learn more, refer to Details for Proposed CY 2016 Revisions to Payment Policies Under PFS.
Shared Savings Program Final Rule
June 9, 2015
The final rule improves several program areas including:
- Creates a new performance-based risk option (Track 3) that includes prospective beneficiary assignment, a higher sharing rate, and the opportunity to use new care coordination tools.
- Permits ACOs to participate in one additional 3-year agreement period under Track 1 and maintain the same maximum sharing rate applicable in their first agreement period.
- Establishes a waiver of the 3-day stay SNF rule for beneficiaries that are prospectively assigned to ACOs under Track 3.
- Streamlines the process for ACOs to access Medicare beneficiary claims data necessary for health care operations, while retaining the opportunity for beneficiaries to decline to have their claims data shared with the ACO.
- Refines the policies for resetting ACO benchmarks to help ensure that the program continues to provide strong incentives for ACOs to improve patient care and generate cost savings, and announces CMS’ intent to propose further improvements to the benchmarking methodology later this year.
- Revises the assignment methodology to remove certain specialty types whose services are not likely to indicate the provision of primary care services. Includes primary care services furnished by nurse practitioners, physician assistants, and clinical nurse specialists.
To learn more, refer to:
2014
- Expand/Collapse
Proposed Rule
December 8, 2014
To learn more, refer to Federal Register December 2014 Proposed Rule.
2011
- Expand/Collapse
Shared Savings Program Final Rule
November 2, 2011
To learn more, refer to Federal Register November 2011 Final Rule.
Proposed Rule
April 7, 2011
To learn more, refer to Federal Register April 2011 Proposed Rule
Other Regulations
To learn more about other applicable regulations, refer to the resources below:
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11/04/2024 01:20 PM