Changes in ACO participants and ACO providers/suppliers during the Agreement Period

Medicare Shared Savings Program Guidance:
Changes in ACO participants and ACO providers/suppliers during the Agreement Period

Under the Shared Savings Program regulations, as part of its application, an ACO must submit and finalize its lists of ACO participants and ACO providers/suppliers.

CMS uses the ACO Participant List submitted as part of the ACO’s application to:

• Screen ACO participant taxpayer identification numbers
• Determine whether the ACO satisfies the requirement to have a minimum of 5,000 assigned beneficiaries
• Establish the historical benchmark
• Perform financial calculations associated with quarterly and annual reports
• Determine preliminary prospective assignment for and during the performance year
• Determine a sample of beneficiaries for quality reporting
• Coordinate participation in the Physician Quality Reporting System under the Shared Savings Program

Additionally, CMS uses the ACO Participant List along with the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) to provide the ACO with a list of the ACO providers/suppliers that have assigned their billings to each ACO participant’s Taxpayer Identification Number.  When they enter the program, ACOs must certify that the ACO provider/supplier list is complete and accurate, or submit changes to CMS and require ACO participants and ACO providers/suppliers update their enrollment in PECOS.

The ACO must maintain, update, and annually give the list of ACO participants and the list of ACO providers/suppliers to CMS at the beginning of each performance year and at other times as specified by CMS.  The ACO must certify the accuracy of these lists at the start of each performance year.  During the term of the participation agreement, an ACO may add or remove ACO participants or ACO provider/suppliers.  An ACO must notify CMS within 30 days of such an addition or removal.  The ACO’s benchmark, risk scores, and preliminary prospective assignment may be adjusted for these changes at CMS’ discretion.  This document gives guidance on how and when such changes will affect various Medicare Shared Savings Program operations.

If you are currently an approved ACO, please see “ACO Participant Agreement Guidance and Annual Deadlines for Approved ACOs” in the Program Announcement section of the SSP ACO Portlet at https://portal.cms.gov.

How changes in ACO participants will affect data sharing

If an ACO participant joins an ACO after the start of a performance year, we will screen the ACO participant and associated ACO providers/suppliers, including screening their program integrity histories and looking for overlapping TINs that are already participating in another ACO or Medicare initiative involving shared savings.  We will provide ACOs with feedback on their participant list changes twice a year. CMS will tell the ACO if there are any issues with the addition of a new ACO participant that could jeopardize the participation agreement the ACO has with CMS.  If all of the issues can be resolved, the ACO will get notification from CMS that the changes to the ACO structure have been approved.  The new ACO participant may then start telling beneficiaries of its participation in the program, and the ACO may begin requesting beneficiary identifiable data for beneficiaries who have gotten primary care services from the new ACO participant consistent with the requirements of the Medicare Shared Savings Program.

If an ACO participant leaves the ACO after the start of a performance year, the ACO participant must remove signs notifying beneficiaries of its participation in the program.  The ACO may continue to request data for a beneficiary seen by the former ACO participant as long as the beneficiary has gotten services from a current ACO participant during the past 12 months or during the course of the current performance year. If a beneficiary hasn’t gotten services from a current ACO participant during the past 12 months or during the course of the current performance year, the ACO must revise its Beneficiary Data Sharing Request file to specify a value of “N” (stop data sharing) for the data field “data sharing request code” for this beneficiary.

How changes in ACO participants will affect how eligible professionals may qualify for the Physician Quality Reporting System (PQRS) Incentive

The Medicare Shared Savings Program will coordinate participation in PQRS under the Shared Savings Program by submitting the certified list of ACO participant TINs to the PQRS program each year.  

Eligible professionals that bill through an ACO participant that joins an ACO after a year has started won’t be eligible to qualify for a PQRS incentive through the Shared Savings Program in that year.   Instead, these eligible professionals may attempt to participate in one of the traditional PQRS individual or group reporting options, and if program requirements are met, to qualify for a PQRS incentive for that year. Eligible professionals that bill through the newly added ACO participant will be eligible to qualify for a PQRS incentive under the Shared Savings Program based on ACO reporting for the next performance year.

Eligible professionals that bill through an ACO participant that leaves an ACO before the end of a year will be eligible to qualify for the PQRS incentive under the Shared Savings Program if the ACO satisfactorily reports the GPRO measures.

How changes in ACO participants will affect assignment, financial reconciliation, sampling for quality reporting, and the quarterly and annual reports

The ACO must maintain, update, and annually give a list of ACO Participants and ACO providers/suppliers to CMS at the beginning of each performance year and at other times as specified by CMS.

We will use the ACO Participant List certified by the ACO at the start of a given performance year to:

• Preliminary prospectively and retrospectively assign beneficiaries to the ACO for that performance year.
• Calculate shared savings/losses for performance year financial reconciliation including interim reconciliation for those ACOs that began participating in 2012 and elected to get an interim reconciliation.
• Create quarterly and annual reports provided to the ACO throughout that performance year.
• Determine the beneficiary sample for quality reporting.

ACO participants who leave the ACO during a performance year will continue to be used in that performance year’s assignment, sampling for quality reporting, financial reconciliation, and quarterly and annual reports.  ACO participants who join the ACO during a performance year won’t be used in that performance year’s assignment, sampling for quality reporting, financial reconciliation, or quarterly and annual reports.  All changes to ACO participants for these reasons will take effect for the next performance year.

Consistent with 42 C.F.R. 425.214(a), we reserve the right to make changes to assignment, sampling for quality reporting, financial reconciliation, and reports during a performance year to reflect changes in ACO participants should the circumstances warrant.  However, absent unusual circumstances, no changes will be made. We do not intend to define every potential unusual circumstance in which we may use our discretion to make changes to assignment, sampling for quality reporting, financial reconciliation and reports during a performance year.  However, examples of unusual circumstances may include if we determine that ACO participants engaged in activities related to avoidance of at-risk beneficiaries or if we determine that the ACO participant has another program integrity issue.

How Changes in ACO Participants will affect the Historical Benchmark

After acceptance into the program and upon execution of the participation agreement with CMS, the ACO must certify the completeness and accuracy of its list of ACO participants.  We set the ACO’s historical benchmark at the start of the agreement period based on the assigned population in each of the three benchmark years by using the ACO Participant List certified by the ACO. The ACO must submit a new certified ACO Participant List at the start of each new performance year. 

CMS will adjust the ACO’s historical benchmark at the start of a performance year if the ACO Participant List that the ACO certified at the start of that performance year differs from the one it certified at the start of the prior performance year. We will use the updated certified ACO Participant List to assign beneficiaries to the ACO in the benchmark period (the 3 years prior to the start of the ACO’s agreement period) in order to determine the ACO’s adjusted historical benchmark. As a result of changes to the ACO’s certified ACO Participant List, we may adjust the historical benchmark upward or downward.  We’ll use the new certified list of ACO participants and the adjusted benchmark for the new performance year’s assignment, quality measurement and sampling, reports for the new performance year, and financial reconciliation. We will provide ACOs with the adjusted Historical Benchmark Report.