CMS Interim Rule – ACO Shared Savings Program

May 13, 2020

 

On April 30, 2020, the Centers for Medicare and Medicaid Services (“CMS”) released an interim rule announcing several changes to do the COVID-19 Public Health Emergency (“PHE”). The interim rule includes the following changes to the Accountable Care Organization (“ACO”) Medicare Shared Savings Program:

ACOs with current agreements set to expire December 31, 2020 may extend their agreements by one year

CMS is giving ACOs with participation agreements expiring December 31, 2020 the opportunity to elect to continue with the Shared Savings Program for one year. ACOs that select this one year extension will remain under their existing historical benchmark for Performance Year (“PY”) 2021. CMS anticipates that ACOs will be able to elect to extend their agreements beginning June 18 until September 22, 2020.

CMS further announced that it will not be accepting applications from new ACOs for a January 1, 2021 start date due to the PHE. However, current ACOs can apply for a SNF 3-day rule waiver, modify existing ACO participant(s) and/or SNF affiliate lists, change their assignment methodology, and elect to move to a higher risk level.

BASIC Track ACOs May Maintain Their Participation Level for One Year

BASIC Track ACOs may elect to maintain their current level of risk for PY 2021. However, ACOs that elect to maintain their current level for PY 2021, will be automatically advanced to the level they would have been in PY 2022 without the election. For example, if an ACO is currently at Level B and elects to maintain Level B for PY 2021, then that ACO will automatically be moved to Level D for PY 2022. CMS anticipates that ACOs eligible to extend their agreement will be able to elect to extend beginning June 18 through September 22, 2020.

The CMS ‘Extreme and Uncontrollable Circumstances’ Policy Applies to PHE

CMS has determined that the Extreme and Uncontrollable Circumstances Policy, which is intended to mitigate shared losses when ACO’s assigned beneficiaries are located in geographic areas impacted by extreme and uncontrollable circumstances, applies to all ACOs for the PHE beginning January 2020. CMS will reduce the amount of an ACO’s shared losses by an amount determined by multiplying the shared losses by the percentage of total performance months affected.

CMS to Adjust Program Calculation to Mitigate Impact of COVID-19 Pandemic

CMS is excluding from the Shared Savings Program all Medicare Part A and B FFS payment amounts for episodes of care for treatment of COVID-19 triggered by an inpatient service. CMS will identify this episode of care based either on: (1) discharges eligible for the 20% DRG adjustment pursuant to the CARES Act; or (2) discharge for acute care inpatient services for treatment of COVID-19 from facilities not reimbursed under the Medicare Inpatient Prospective Payment System. CMS defines an episode of care for treatment of COVID-19 as starting in the month in which the inpatient stay begins as identified by the admission date, all months during the inpatient stay, and the month following the end of the inpatient stay as indicated by the discharge date.
To compensate for such anticipated impacts from COVID-19, CMS is going to retrospectively apply a historical benchmark update based on national growth rates, regional growth rates or a blend of the two.

CMS has Expanded the Definition of ‘Primary Care Services’ to Include Certain Telehealth and Telephonic Services

CMS has expanded the definition of ‘primary care services’ to include the following codes for virtual check-ins, e-visits and telephonic communications for PY 2020 and any additional performance year that begins during the PHE:

  • Remote evaluation of patient video/images HCPCS code G2010;
  • virtual check-in HCPCS code G2012;
  • online digital evaluation and management services (e-visit) CPT codes 99421, 99422 and 99423; and
  • telephone evaluation and management service CPT codes 99441, 99442, and 99443.

The full interim rule can be found at:
https://www.cms.gov/files/document/covid-medicare-and-medicaid-ifc2.pdf

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Should you have any questions regarding the above, please contact the Garfunkel Wild attorney with whom you regularly work, or contact us at info@garfunkelwild.com.

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