Program Guidance & Specifications

Program Guidance & Specifications

Find guidance and specifications pertaining to Accountable Care Organizations (ACOs) applying to and/or participating in the Medicare Shared Savings Program (Shared Savings Program).

Program Participation

            Program Participation Information

            Provider Participation

            Exclusivity Rule

            Other CMS Innovation Center Initiatives

            Public Reporting

            Compliance Monitoring

            Beneficiary Assignment

            Financial Reconciliation

            Electronic Funds Transfer Authorization Agreement

            Telehealth

Beneficiary Information

            Beneficiary Notification and Marketing

            Empowering Patients to Make Decisions about Their Healthcare

            Beneficiary Incentive Program Guidance

Quality

            Quality Reporting and Measurement

            Prior Years Quality Documentation

            Quality Payment Program

            Quality Measurement Performance Interaction Resources

Promoting Interoperability

Data and Report Sharing

Financial, Beneficiary Assignment, and Quality Performance Standard

            Accountable Care Prospective Trend Specifications

            Current Years Shared Savings and Losses, Assignment Methodology and Quality Performance Standard Specifications

Program Participation

Program Participation Information 

For agreement periods beginning on July 1, 2019, and in subsequent years, ACOs agree to participate in the Shared Savings Program for a period of no less than five years, known as the agreement period. The agreement period is made up of performance years that follow similar operational processes.

ACOs may participate in the Shared Savings Program for agreement periods of at least five years, under one of two tracks: the BASIC track (which includes a glide path for eligible ACOs), or the ENHANCED track, which offers the highest level of risk and potential reward. ACOs participating in the BASIC track’s glide path may begin under a one-sided model and progress through incremental levels of increasing risk and potential reward.

For more information about the participation options available to ACOs, refer to the About the Program webpage.

Over the course of an agreement period, ACOs:

  • Coordinate care for beneficiaries, measure and improve quality, and publicly report performance results;
  • Prepare for the next performance year by making sure contact information is current in CMS systems, maintaining their ACO Participant List and Skilled Nursing Facility (SNF) Affiliate List (if applicable), and completing the Annual Certification process; and 
  • Receive annual financial and quality performance results.

Provider Participation

To participate in the Shared Savings Program, Medicare-enrolled providers and suppliers must form or join an ACO, and the ACO must apply and be accepted to the Shared Savings Program. Providers and suppliers may contact other ACO participants in the region, state, or national professional associations to investigate opportunities to join an ACO. ACOs must have at least 5,000 Medicare fee-for-service (FFS) beneficiaries assigned to their ACO in each benchmark year to be eligible for participation in the Shared Savings Program.

Exclusivity Rule

Within the Shared Savings Program:

Any ACO participant, as identified by the taxpayer identification number (TIN), that has a specialty used in assignment (reference 42 CFR 425.402), and bills Medicare for primary care services must be exclusive to a single Shared Savings Program ACO. However, individual practitioners, identified by individual National Provider Identifiers (NPIs), are free to participate in multiple ACOs if they bill under several different TINs.

Among Medicare shared savings initiatives:

During a performance year, a Medicare-enrolled TIN can participate in only one Medicare shared savings initiative, including certain CMS Innovation Center initiatives. For a complete list of CMS Innovation Center models and resources for program overlap, visit the CMS Innovation Center website.

Other CMS Innovation Center Initiatives

There are several Medicare initiatives that aim to promote quality improvement while lowering the growth in health care expenditures. Although these programs are separate and distinct, they interact in key areas.

Shared Savings Initiatives

ACO participants cannot participate in multiple Medicare initiatives involving shared savings. These include, but are not limited to:

  • ACO Realizing Equity, Access, and Community Health (REACH) Model
  • Independence at Home Demonstration with a shared savings arrangement (The Patient Protection and Affordable Care Act Sec. 3024)
  • Kidney Care Choices (KCC) Model
  • Vermont All-Payer ACO Model

Medicare and the CMS Innovation Center may introduce additional programs, demonstrations, or models with a Medicare shared savings component in the future.

Non-Shared Savings Initiatives

Shared Savings Program ACOs can participate in CMS Innovation Center initiatives that do not involve shared savings. These include, but are not limited to:

  • 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, visit the CMS Innovation Center website.

Public Reporting

The Shared Savings Program requires ACOs to create and maintain a dedicated webpage to publicly report required organizational and programmatic information, such as organizational contact information and performance results. CMS provides instructions to ACOs ahead of each public reporting cycle.

Compliance Monitoring

Throughout the year, the Shared Savings Program expects ACOs to comply with program requirements. Each ACO must have a designated compliance official and a detailed compliance plan. To participate in the Shared Savings Program, each ACO must have a compliance plan in accordance with 42 CFR § 425.300.

Beneficiary Assignment

Beneficiary assignment contributes to key program operations, such as calculating the ACO’s financial benchmark, assessing the ACO’s financial performance after the close of each performance year, and determining the ACO’s sample of beneficiaries for quality reporting.

Financial Reconciliation

ACOs are rewarded when they lower growth in Medicare Parts A and B expenditures (relative to their benchmark) while meeting quality performance standards at the same time. Performance year financial reconciliation occurs annually after CMS assesses quality performance.

Participating ACOs are encouraged to reference the program’s financial and beneficiary assignment specifications for detailed information on how the Shared Savings Program assigns beneficiaries to each ACO and calculates a historical financial benchmark from which to assess annual financial performance, and ultimately, eligibility for an earned shared savings payment. CMS adjudicates any earned shared savings payments or incurred losses in the fall following each performance year.

Electronic Funds Transfer Authorization Agreement

Participating ACOs must maintain a current Electronic Funds Transfer Authorization Agreement (Form CMS-588) to receive shared savings payments. Please refer to the Application Guidance & Toolkit webpage for further information.

Telehealth 

With the passage of the Bipartisan Budget Act of 2018, new flexibilities were granted for physicians and practitioners in certain ACOs in the delivery of services through telehealth for dates of service on or after January 1, 2020. Providers and suppliers in ACOs that are in a two-sided risk track and that choose prospective assignment may bill for certain services without the geographic limitations that usually apply to FFS telehealth coverage. Also, the home of the beneficiary may qualify as an originating site. 

See the Shared Savings Program Telehealth Fact Sheet (PDF); for details, including which telehealth services are part of the expanded benefit, and how to bill them.

Beneficiary Information 

Beneficiary Notification and Marketing

An ACO or ACO participant must provide each beneficiary with a Beneficiary Information Notification before or at the first primary care visit of the agreement period. ACO participants must post the appropriate signage template in all ACO facilities and make Beneficiary Information Notification’s available to beneficiaries upon request in settings where beneficiaries receive primary care services. The notifications must include information about the following:

  1. That the ACO's providers/suppliers are participating in the Shared Savings Program.
  2. The beneficiary has the option to decline data sharing; and
  3. The beneficiary has the ability to choose where they receive their care. The notification must include the 1-800-MEDICARE support line so that beneficiaries have the instructions on how they may identify or change their provider for the purposes of voluntary alignment.

In addition to furnishing the Beneficiary Information Notification prior to or at the first primary care visit of the agreement period and posting the signage in all facilities, an ACO must also furnish a follow- up communication at the beneficiary’s next primary care visit or within 180 -days of the beneficiary receiving the first notification. The follow-up communication affords the ACO the opportunity to have a meaningful dialog with a beneficiary about the benefits of receiving care in an ACO. The follow up communication offers greater program transparency and empowers beneficiaries to make informed decisions about where they receive their care.

There are multiple acceptable options for ACOs to use when operationalizing this requirement. The follow up communication provided to a beneficiary may be furnished in a verbal or written format. However, sending the original Beneficiary Information Notification a second time will not meet this requirement. The follow up communication is intended to provide the beneficiary with a meaningful opportunity to ask any outstanding questions they might have and serve as a tool to reduce beneficiary confusion and increase comprehension of the ACO program. The most desirable form of follow-up would occur face to face (for instance, at a primary care office visit), where the beneficiary and provider can discuss ACO benefits and address specific patient concerns. Examples of appropriate modes of conducting this follow-up communication can include disseminating an outreach via a secure patient portal, postal mail, email, or a telephone or video visit. ACOs must maintain a record of all follow-up communications furnished during the agreement period and make this record available to CMS upon request.

If an ACO operates a Beneficiary Incentive Program (BIP), the ACO or its ACO participants must also notify Medicare FFS beneficiaries that it is operating a BIP.

Empowering Patients to Make Decisions About Their Healthcare

Voluntary alignment is the process that lets Medicare FFS beneficiaries select, or “voluntarily align” with a primary clinician. ACOs must notify beneficiaries of their ability to, and the process by which, they may identify or change the clinician they chose for the purposes of voluntary alignment.

Medicare FFS beneficiaries can log into Medicare.gov and choose their primary clinician, the health care provider they believe is responsible for coordinating their overall care. The Shared Savings Program will use the eligible beneficiary’s selection of a primary clinician on Medicare.gov to take priority over the claims-based assignment methodology. For more information, refer to the following resources:

Beneficiary Incentive Program Guidance

Participating ACOs approved to establish and operate a BIP may provide an incentive payment with a value of up to $20 to each assigned beneficiary for each qualifying primary care service received.

Quality 

Quality Reporting and Measurement

Participating ACOs must report quality data to CMS after the close of every performance year to be eligible to share in any earned shared savings and to avoid sharing losses at the maximum level. CMS measures every ACO’s quality performance using standard methods.

Beginning with PY 2021, ACOs participating in the Shared Savings Program have been required to report through the Alternative Payment Model (APM) Performance Pathway (APP) for purposes of assessing their Shared Savings Program quality performance.

The APP is designed to:

  • Reduce reporting burden
  • Create new scoring opportunities for participants in Merit-based Incentive Payment System (MIPS) APMs
  • Encourage participation in APMs

To learn more about the Shared Savings Program quality measurement and the APP, refer to the resources below:

To learn more about the measure specifications and benchmarks applicable to the APP for PY 2023, refer to:

To learn more about the measure specifications and benchmarks applicable to the APP for PY 2024, refer to:

Prior Years Quality Documentation

Quality Payment Program

The Quality Payment Program improves Medicare by helping providers focus on care quality and the one thing that matters most—making patients healthier.  

The Quality Payment Program has two tracks from which clinicians can choose: 

  1. Advanced Alternative Payment Models (APMs): Includes clinicians who are in ACOs participating in the Shared Savings Program Level E of the BASIC track or the ENHANCED track. 
  2. Merit-Based Incentive Payment System (MIPS): Includes MIPS eligible clinicians who are in ACOs participating in the Shared Savings Program under Levels A, B, C, or D of the BASIC track. 

Clinicians can view their QPP participation status by performance year, by visiting the QPP Participation Status Lookup Tool and entering their 10-digit National Provider Identifier number. Questions about the QPP Participation Status Lookup Tool may be directed to the QPP Service Center at 1-866-288-8292, (TTY) 1-877-715-6222 or by email at QPP@cms.hhs.gov. 

To learn more about Quality Payment Program and Shared Savings Program interaction, visit the Quality Payment Program Resource Library webpage. 
 

Quality Measurement Performance Program Interactions Resources 

For more information on interactions between the Shared Savings Program and other CMS initiatives, please reference:

  • Interaction with Other Medicare Initiatives: Provides an overview of how the QPP and other CMS Innovation Center initiatives intersect with the Shared Savings Program quality measurement.
  • QPP Resource Library: Presents QPP resources, including fact sheets describing the interaction between the Shared Savings Program and the QPP.

Promoting Interoperability

Unless excluded, for performance years beginning on or after January 1, 2025, an ACO participant, ACO provider/supplier, and ACO professional that is a MIPS eligible clinician, Qualifying APM Participant (QP), or Partial Qualifying APM Participant (Partial QP) must:

  • Report the MIPS Promoting Interoperability performance category measures and requirements to MIPS at the individual, group, virtual group, or APM Entity level (i.e., ACO reports on behalf of its clinicians); and
  • Earn a performance category score for the MIPS Promoting Interoperability performance category at the individual, group, virtual group, or APM Entity level.

This requirement applies regardless of the Shared Savings Program track in which the ACO participant, ACO provider/supplier, or ACO professional participates.

Data and Report Sharing

CMS provides ACOs with information on their assigned population and financial performance at the start of the agreement period and routinely during the performance year. To better treat patients and to coordinate their care, Shared Savings Program ACOs may request to receive monthly CCLF files on Medicare FFS beneficiaries who have not declined to share their data.

Financial, Beneficiary Assignment, and Quality Performance Standard Specifications

Participating ACOs are encouraged to reference the program’s financial and beneficiary assignment specifications for detailed information on how the Shared Savings Program assigns beneficiaries to each ACO and calculates a historical financial benchmark from which to assess annual financial performance, and ultimately, eligibility for an earned shared savings payment.

Accountable Care Prospective Trend Specifications

Accountable Care Prospective Trend (ACPT) and Three-Way Blended Benchmark Update Factor Specifications Version 1 (PDF): Describes the ACPT which is a component of the three-way blended update factor to the historical benchmark applicable to ACOs entering agreement periods beginning on January 1, 2024, and in subsequent years, as outlined in the CY 2023 Physician Fee Schedule Final Rule (87 FR 69881).

Current Years Shared Savings and Losses and Assignment Methodology and Quality Performance Standard Specifications

ACOs that will be reconciled for PY 2022 should refer to the benchmarking methodology and assignment sections described in Version 10 (PDF). All ACOs participating in PY 2023 should refer to Version 11 (PDF). For prior years information please reference the “Prior Years Shared Savings and Losses and Assignment Methodology Specifications” section further below.

 

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Page Last Modified:
10/28/2024 01:10 PM
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