11 things to know about the MSSP ACO final rule

CMS released its final rule for accountable care organizations under the Medicare Shared Savings Program Thursday. Here are 11 key final actions stated in the rule.

1. The rule creates a Track 3. This is a two-sided risk model that has a higher sharing rate of 75 percent in conjunction with accepting risk for up to 75 percent of all losses, prospective beneficiary assignments and the opportunity to apply for a waiver for the three-day SNF rule, which would allow payment for SNF services when a beneficiary is admitted to a SNF without a prior three-day inpatient stay.

2. Once a beneficiary is prospectively assigned to a Track 3 ACO, the beneficiary will not be eligible for assignment to a different ACO, even if the beneficiary chooses to receive several primary care services from another ACO during the relevant benchmark year.

3. As for minimum shared savings and minimum loss rates, CMS finalized a rule for Track 2 ACOs that leaves them with the choice of symmetrical MSR/MLR. This breaks down to (a) no MSR/MLR, (b) symmetrical MSR/MLR in 0.5 percent increments between 0.5 percent and 2 percent, or symmetrical MSR/MLR to vary based upon the number of assigned beneficiaries (as it does in Track 1). The Track 3 risk model will follow the same rule for MSR/MLR as Track 2 under the final rule.

4. The rule finalizes policies related to ACO benchmarks. Under the rule, benchmarks will be reset in a second or subsequent agreement period by integrating financial performance and equally weighting benchmarks for subsequent periods. This is intended to make continued participation more attractive, as the longer the agreement period, the greater an ACO's chance of building on success, or, conversely, continuing its failure. "Therefore, we believe rebasing every three years, at the start of each agreement period, is important to protect both the Trust Funds and ACOs," CMS wrote.

5. The final rule eliminates the requirement that ACOs starting the MSSP under Track 1 must transition to Track 2 after one agreement period if they wish to continue as participants in the program. The revision will allow ACOs that have completed a three-year agreement under Track 1 to enter another three-year agreement under Track 1. ACOs may operate under the one-sided model for a maximum of two agreement periods.

6. The rule requires ACOs to submit documents demonstrating that its participants, suppliers and other individuals or entities performing functions related to the ACO comply with the rules of the MSSP. This requirement will be part of the ACO application process and CMS can seek verification of compliance any time thereafter. CMS said it will not "routinely" request copies of executed agreements between the ACO and its participants, but reserves the right to request this information upon application, renewal or any other time for monitoring purposes. CMS will not require these changes to be incorporated into ACO participant agreements submitted for the 2016 performance year.

7. Previously terminated Track 1 ACOs can reapply under the one-sided or two-sided model. Based on when the ACO terminated its previous agreement, CMS will differentiate whether it is applying for its first or second agreement period under Track 1.

8. CMS did not finalize its proposed amendment to reduce the maximum sharing rate during Track 1 ACOs' second agreement. ACOs on this track, in their second agreement period, are eligible for shared savings payments of up to 50 percent of all savings. No changes were made to Track 2 ACOs' sharing rate either — those ACOs are still eligible for up to 60 percent of all savings.

9. ACOs entering a two-sided model are required to establish a repayment mechanism at the beginning of a three-year agreement period. Under these new requirements, ACOs must demonstrate that they would be able to repay shared losses incurred at any time of the agreement and for the "tail period" or reasonable window of time at the end of each agreement (the length of the tail period is to be established in CMS guidance).  

10. ACOs must maintain a "dedicated webpage" on which they must publicly report information using a template specified by CMS that is not subject to marketing review. This webpage must also identify the key clinical and administrative leaders within the ACO, members of its governing body and the types of participants that form the organization. Other information required on the webpage includes:
·    Name and location of the ACO
·    Primary contact
·    Shared savings and losses information
·    Performance on all quality measures
·    Use of payment rule waivers if applicable

11. CMS is exploring operational processes to develop a methodology that will let ACOs "split" ACO participants or providers and suppliers into two different risk tracks. "We may revisit this approach in future rulemaking as infrastructure evolves to support this new alternative," the final rule stated.

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